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.

ALASKA PSYCHIATRIC INSTITUTE 3700 PIPER STREET ANCHORAGE, AK 99508 July 1, 2021
VIOLATION: PATIENT RIGHTS Tag No: A0115
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Based on policy review, record review, observations, and interviews, the hospital failed to meet the Condition of Participation of Patient Rights in that the hospital failed to ensure patients received care in a safe setting. These failures had the potential to affect all 59 inpatients and any future patient admitted to the hospital.

Findings include:
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1. The hospital failed to ensure patients received care in a safe setting. The hospital failed to identify a protruding toilet tissue holder as a ligature risk in all bathrooms in patient rooms and failed to implement a sufficient mitigation plan for the hospital-identified ligature risk caused by the bathroom doors in all patient rooms. (Refer to A0144)

2. The hospital failed to ensure patients were free from abuse by failure to remove the alleged perpetrator from direct patient care until the abuse allegation investigation was complete. The facility failed to conduct an investigation into an allegation of abuse for one patient reviewed for abuse. (Refer to A0145)

3. The hospital failed to follow the hospital's policy for patient rights by continuously holding a medication cup to a patient's mouth for two to three minutes in an attempt to administer oral medications. (Refer to A0131)

This deficiency was cited based on complaints: AK 047 and AK 974
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VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
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Based on policy review, observations, and interview, the facility failed to ensure patient's rights were protected by allowing patients to refuse medications. The Registered Nurse (RN) failed to follow the facility's policy for patient rights by continuously holding a medication cup to a patient's mouth for two to three minutes in attempt to administer oral medications for one (Patient #1) of three patients reviewed for patient rights. This failure had the potential to affect all patients receiving oral medications at the facility.

Finding include:

Review of the facility policy titled, "Patient Rights" effective 3/14/19 revealed all patients will be informed of their patient rights upon admission to the hospital. Patient rights will be included in the patient handbook and will be posted publicly on the patient units.

Review of the Patient Rights and Responsibilities document posted on patient units revealed "you have the right to refuse medications unless it is an emergency order by the judge."

Observations on 7/01/21 at 9:00 am of a closed-circuit television (CCTV) recording of the 12/19/20 incident in the Chilkat Unit Dining Room involving Patient #1 and Former Licensed Nurse (FLN) #1. Observation of the CCTV recording revealed on 12/19/20 at 7:41 am Licensed Nurse, LN #7, entered the dining room and attempted to administer oral medications to Patient #1. Patient #1 was seen selecting and swallowing all the oral medications except for one pill that remained in the medicine cup. LN #7 was observed to verbally persuade Patient #1 to take the remaining pill without physically touching the patient. At 7:45 am FLN #1 was observed taking Patient #1's medicine cup and holding to the patient's mouth. From 7:45 am to 7:47 am, FLN #1 was observed continually holding the medicine cup to Patient #1's mouth with one hand and holding the patient's back with the other hand. During the two minutes of continuous attempt to get Patient #1 to swallow the remaining pill, Patient #1 was observed attempting to turn their head and move their body away from FLN #1 in attempt to avoid swallowing the medication. At 7:48 am FLN #1 was observed pouring the pill onto a plastic spoon and placing it in Patient #1's mouth. The patient appeared to have swallowed the medication at that time. (Refer to A0145)

During the interview on 6/30/21 at 1:45 pm, NSS, LN #9 stated what FLN #1 was observed doing to Patient #1 on the 12/19/20 CCTV recording was a violation of the patient's right to refuse to take medications.

This deficiency was cited based on complaint # AK 974

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VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
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Based on observation, policy review, document review, and interviews, the hospital failed to ensure patients received care in a safe setting. The hospital failed to identify a protruding toilet tissue holder as a ligature risk in all bathrooms in patient rooms and failed to implement a sufficient mitigation plan for the hospital-identified ligature risk caused by the bathroom doors in all patient rooms. These failures had the potential to affect all 59 inpatients and any future patient admitted to the hospital.

Findings include:

Review of the hospital's policy titled "Patient Rights," effective 3/14/19, did not indicate that the patient rights included the right to receive care in a safe setting.

Review of the "Patient Rights & [and] Responsibilities Alaska Psychiatric Institute (API)," revised August 2017, indicated "...You have the Right to: ... Receive treatment in a safe, respectful, and the least restrictive appropriate setting..."

Review of the hospital's mitigation plan for the identified patient bathroom door ligature risk indicated "... Staff are aware of ligature risk with current bathroom doors and will continue monitoring during 15 min [minutes] checks... 19-bathroom doors removed. 1 door reinstalled per nursing due to need to keep pt. [patient] from bathroom access..." There was no documentation that the time interval of patient observations conducted by staff had been increased.

Observation on the Susitna and Katmai Units, which housed adult patients, on 6/29/21 from 9:35 am to 11:10 am revealed the bathroom doors in all the patients' rooms had a slanted opening across the top of the door with piano-type hinges in the door closure. Observation of the toilet tissue dispenser in the patient bathrooms in all patient rooms on these units revealed the tissue holder had a protruding metal bar to which the toilet tissue roll could be slid on and off.

Observation in Room S1 on the Susitna Unit on 6/29/21 at 9:45 am, the Clinical Coordinator of Education (CCE) tied a pillow case around the inner edge of the tissue holder where it attached to the mounting and pulled forward and to the right. The pillow case did not release and presented a risk for hanging.

In an interview on 6/29/21 at 9:45 am, CCE stated all patient bathrooms have the same type of toilet tissue holder described above The CCE confirmed when he/she pulled on the pillow case, it did not release. CCE confirmed the tissue holder was a ligature risk and had not been identified by the hospital. The CCE stated the bathroom doors in patient rooms had been identified as a ligature risk, and plans were in place to change the doors to a door that would not present a ligature risk.

In an interview on 6/30/21 at 2:08 pm, The Director of Clinical Services (DCS) stated, "... I don't know what change there is" with the mitigation plan. DCS stated other than to remove the doors, "I don't see any change." When asked if DCS agreed that their mitigation plan doesn't address a change from what they had in place before the risk was identified, DCS stated "the only thing that has changed is to remove the doors if needed."

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VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on observation, policy review, record review, document review, and interviews, the hospital failed to ensure patients were free from abuse by failure to remove the alleged perpetrator from direct patient care until the abuse allegation investigation was complete for two (Patient #1, Patient #5) of five patient records reviewed for abuse; failed to conduct a thorough investigation of an allegation of abuse for one (Patient #5) of five patient records reviewed for abuse; and failed to ensure the hospital policy required that an investigation be conducted for all allegations of abuse from a sample of 11 patients. This failure had the potential to affect all 59 inpatients and any future patient admitted to the hospital.


Findings include:

Review of the hospital's policy titled "Abuse and Neglect Prevention Policy," effective 03/14/19, indicated ". . .It is the policy of API [Alaska Psychiatric Institute] for patients to have the right to treatment in a setting that provides physical and emotional safety and freedom from all forms of abuse or neglect. All cases of suspected abuse or neglect, as defined in this policy, whether and actual injury has occurred, will be reported, and investigated promptly in compliance with state and federal regulations... The CEO [Chief Executive Officer], QAPI [quality assessment and performance improvement] Director, or designee will immediately complete mandatory requirements ... X. Any staff member alleged to have abused or neglected a patient will be immediately removed from patient care duties and their access to patient care will be restricted. When the ASM, or designee determines staff member must be removed from patient care and restricted care areas, the staff member's immediate supervisor will be notified, and the staff member will immediately be removed from patient care pending an investigation..." The policy did not indicate regarding the process for conducting an investigation into allegation of abuse and to whom the results of the investigation would be reported.


Review of the hospital's policy titled "Unusual Occurrence reporting," effective 3/14/19. Indicated "...Unusual Occurrences will be reported by any API Staff whenever they are primarily involved in or observe an unusual occurrence, or are directed to report such by a supervisor or the Risk Manager (RM) RM/designee will determine if an investigation is required and will take appropriate action to initiate..."


1. Review of the "Alaska Psychiatric Institute - Unusual Occurrence Report (UOR)" indicated the date of the incident was 4/19/21, the complainant was Patient #5, the nursing staff involved was Licensed Nurse (LN) #1 and LN #2, and the witnesses were LN #3 and Psychiatric Nursing Assistant (PNA) #1. Further review indicated the incident type was "Allegation of Patient Maltreatment/Misconduct Involving a Patient (Abuse/Neglect/Exploitation/Other)..." Review of the section titled "Describe Supervisory Review and Actions Taken" indicated LN #2 documented on 4/19/21 at 3:22 am "pt [patient] accused myself of touching [his/her] buttocks and wanted to press charges. I instructed the unit RN [registered nurse] to call APD [Alaska Police Department]. Once APD arrived, I instructed the unit RNs to engage APD & [and] follow their instructions for the investigation. APS report submitted. I called on call Director of Nursing & [and] emailed senior staff [name of senior staff]." Review of the section titled "Risk Manager Review" indicated "No Action Taken" and "Describe if applicable: Advocate video review video review completed - no male PNA contact identified."


Review of the "Information Note" documented 4/19/21 by LN #1 and attached to the "Alaska Psychiatric Institute - Unusual Occurrence Report (UOR)" indicated "Data Pt asked a PNA to get a nurse to get [his/her] albuterol [medication used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases such as asthma and chronic obstructive pulmonary disease]. RN went into the room to give [him/her] albuterol then pt started to escalate. Pt reported that [he/she] wanted to 'fucking press charges" d/t [due to] a staff member "touching my bottom". Pt pointed in [his/her] L [left[ lower glutes. Action NSS [nursing service supervisor] notified. APD contacted. Response NSS notified. APD contacted."


Review of the "Adult Protective Services Intake Report" dated 4/19/21 at 3:56 am documented by LN #1 indicated the alleged perpetrator was LN #2. Review of "Description of Incident" indicated "Does the Alleged Perpetrator have access to the Involved Person? Alleged perpetrator is a supervisor in the hospital...(Describe the circumstances leading to the incident or death.) Patient was initially hyperventilating & exhibiting s/s [signs and symptoms] of anxiety. Pt was offered interventions as per nursing standards & protocol. Pt was not responsive to interventions given. Supervisor was notified of the patient's behavior. Patient was seen by the supervisor with 1 RN staff & 1 Nursing Assistant as witnesses. Patient was assessed then it was deemed by the supervisor that patient can be observed at this time. If patient was danger to self, other interventions would be placed. Then at 1240 [12:40 am], patient asked a nursing assistant to get a nurse to administer albuterol inhaler [medication used to treat wheezing and difficulty breathing]. Patient became escalated after and started to cry. Patient made allegations of a male staff touching [his/her] bottom. Patient stated '[he/she] was asking me questions if I want to kill myself". Patient requested to press charges to the alleged staff. Nurse made appropriate notifications to the appropriate personnel. APD was notified. Patient was seen & interviewed..."


Review of a typed report signed by Acting Risk Manager (ARM) and Patient Advocate indicated "4/19/21 @ [at] 0147 [1:47 am] event A full day of video review was conducted in observation of the client's routine and daily activities regarding the alleged abuse. There was no observable video evidence of any kind that substantiate the allegation of abuse."


Review of Patient #5's medical record under the "Summary" and "Visit" tabs indicated Patient #5 was admitted on [DATE] and discharged on [DATE]. Further review indicated Patient #5's diagnoses, located under the "Diagnosis" tab, included borderline personality disorder, suicidal ideations, asthma, and unspecified mood [affective] disorder. Further review under the "Notes" tab indicated documentation by LN #2 on 4/18/21 at 11:15 pm of "I received a call from LN #1 regarding this patient [Patient #5]. [Patient #5] has been breathing heavily and fast. [Patient #5] O2 sat [oxygen saturation] was 96-97 [per cent]. I assessed this pt myself and saw [Patient #5] on the floor between the end of the bed and wall side lying with [Patient #5] face buried in a crumpled-up blanket breathing heavily and wheezing. I asked [Patient #5] if [Patient #5] was attempting to kill himself/herself and [Patient #5] shook his/her head "no" I framed this question differently and [Patient #5] continued to deny suicide attempt. I asked [Patient #5] how I could help him/her through this episode but [Patient #5] declined to answer. I consulted with the RNs and recommended a safety blanket. RN will continue to monitor the patient and order a safety blanket and other safety orders if [Patient #5] self-harms with his/her blanket, other linen, clothing, or objects. This appears to be a similar behavior from [Patient #5] last visit that eventually self-resolved."


Review of the "...Locator/Activity Sheet" presented for review by Director of Quality (DQ) indicated Patient #5 was in his/her room awake on 4/18/21 from 11:00 pm to 11:45 pm. Further review indicated Patient #5 was in his/her room awake or sleeping on 4/19/21 at 12:00 am through 5:15 am.


The hospital presented no documentation that an investigation had been conducted of the allegation of abuse that included interviews with and/or written statements by all staff involved in or witnessing the incident. There was no documentation presented that indicated LN #2 was relieved of duties while an investigation was being conducted.


In an interview on 6/30/21 at 9:27 am, PNA #3 stated the video cameras do not have views inside the patient rooms. PNA #3 stated the views seen by video include the entrance to the unit, the restraint/seclusion room, the outside recreation area, and the entrance at the main street. PNA #3 stated security has video views of each of the three hallways on the unit and has a view from the camera located above the desk where the PNA sits to observe the halls.

In an interview on 6/30/21 at 1:35 pm, ARM stated as the Patient Advocate, whatever the patient tells him/her, "I take at face value unless proven otherwise." ARM stated the former Risk Manager requested that ARM view the video of the 24-hour time period in which the incident was alleged to have occurred. ARM stated it is the hospital's policy that no staff should ever isolate themselves with a patient. ARM stated, with that in the back of his/her mind, when he/she was looking at the video, and for the entirety of the all the video he/she observed for the 24-hour period, no staff was observed to be in isolation with the client. ARM stated when he/she saw the patient go in his/her room, no staff went in the room. ARM stated the Risk Manager was supposed to review the patient's medical record and any follow-up documentation. ARM stated he/she did not see any documentation other than what the surveyor had been given to review. When the PNA observation record was shown to ARM, ARM stated the video showed Patient #5 came out his/her room during intervals every 15-minute observation checks. ARM stated he/she knows at after reviewing the video, he/she never saw staff go in Patient #5's room alone. ARM confirmed he/she had no documentation of an investigation of the allegation of abuse by Patient #5 to present.


In an interview on 6/30/21 at 3:28 pm, DQ stated that the hospital does not have any documentation to present that an investigation was conducted. DQ stated the practice is that if an event occurs, the video is stored. DQ further stated when they "don't have evidence [that the allegation occurred], the practice is that they don't keep those clips of video." DQ confirmed the hospital no longer had video recordings of the incident. DQ stated an investigation should be conducted for all allegations of abuse.


In an interview on 7/1/21 at 8:17 am, DQ confirmed LN #2 was not relieved of duties after Patient #5 alleged sexual abuse had occurred.


2. Observations on 7/01/21 at 9:00 am of a closed-circuit television (CCTV) recording of the 12/19/20 incident in the Chilkat Unit Dining Room involving Patient 1 and Former Licensed Nursing (FLN) #1 revealed on 12/19/20 at 7:41 am, LN #7 entered the dining room and attempted to administer oral medications to Patient #1. Patient #1 was seen selecting and swallowing all the oral medications except for one pill that remained in the medicine cup. LN #7 was observed to verbally persuade Patient #1 to take the remaining pill without physically touching the patient. At 7:45 am, FLN #1 was observed taking Patient #1's medicine cup and holding to the patient's mouth from 7:45 am to 7:47 am. FLN #1 was observed continually holding the medicine cup to Patient #1's mouth with one hand and holding the patient's back with the other hand. During the two minutes of continuous attempt to get Patient #1 to swallow the remaining pill, Patient #1 was observed attempting to turn his/her head and move his/her body away from FLN #1 in attempt to avoid swallowing the medication. At 7:48 am FLN #1 was observed pouring the pill onto a plastic spoon and placing it in Patient #1's mouth. The patient appeared to have swallowed the medication at that time.

Review of Patient #1's medical record revealed the patient was admitted on [DATE] and discharged on [DATE] for a condition of grave disability. Review of Patient #1's "Admission Psychiatric Evaluation" dated 12/02/20, described the patient as being uncooperative, impulsive, grabbing and hitting at staff at times, copying/mimicking staff actions at times. Review Patient #1's "Multidisciplinary Treatment Plan" dated 12/12/20 revealed the patient declined to meet with the treatment team due psychosis. Review of the patient's "Discharge Summary" dated 2/09/21 revealed the patient was discharged with final diagnoses of catatonic schizophrenia.


Review of an "UOR" dated 12/19/20 revealed the incident was documented by the Nursing Shift Supervisor (NSS). Further review of the UOR revealed the NSS filed a report with Adult Protection Services regarding the 12/19/20 incident between FLN #1 and Patient #1. An internal investigation and interviews were documented in the UOR.


Review of the December 2020 "Executive Team - Call Schedule" revealed individual administrative staff members were assigned to each day of the month. Further review of the on-call schedule revealed the Director of Nursing (DON) was the executive to be on-call on 12/19/20.


Interview conducted on 6/30/21 at 10:00 am, LN #7 revealed he/she did recall the events on 12/19/21 between Patient #1 and FLN #1. LN #7 reported after Patient #1 initially refused to take one of the medications the nurse had attempted to administer to the patient, the nurse observed FLN #1 forcibly administer the oral medication to Patient #1 by continuously holding the medicine cup to the patient's mouth until the patient relented and swallowed the pill. LN#7 stated Patient #1 voiced "no" while FLN #1 was attempting to get the patient to swallow the pill. Immediately following the incident in the Chilkat Unit, LN #7 went to the NSS, LN #9 and reported what he/she observed. LN #7 physical abused Patient #1 by forcing the patient to swallow the medication. After reporting the allegation of abuse to the NSS, FLN #1 was allowed to continue to work the remainder of the shift on the Chilkat Unit and to have access to Patient #1.


Interview conducted on 6/30/21 at 10:35 am, FLN #1 denied on 12/19/20 of using physical force to get Patient #1 to swallow a medication. However, following the 12/19/20 incident, the NSS came to the Chilkat Unit and had FLN #1 watch the recorded CCTV incident with the NSS. After reviewing the recording, FLN #1 was allowed to work the remainder of the shift on the Chilkat Unit where Patient #1 is assigned.


Interview conducted on 6/30/21 at 1:00 pm, LN #9 revealed the nurse was the assigned NSS at the time of the 12/19/20 incident between FLN #1 and Patient #1. During the interview, LN #9 revealed becoming aware of the incident when LN #7 appeared and reported an alleged physical abuse of a Patient #1 by FLN #1. After receiving the report of possible physical abuse, the NSS watched the CCTV recording in private. During the interview, LN #9 stated the recording revealed Patient #1 shaking their head "no" as FLN #1 attempted to pour a pill from a medicine cup into the patient's mouth. At one-point FLN #1 pushed the patient's head back to force the patient to take the medication. Being unsuccessful, FLN #1 then placed the pill on a plastic spoon and placed into Patient #1's mouth. Following the NSS observation of the recorded incident, FLN #1 was called into the NSS's office to also watch the recording. The NSS stated he/she counseled FLN #1 at that time that the patient had the right to refuse the medication.


During the interview with NSS,LN #9 stated what FLN #1 was observed doing to Patient #1 on the 12/19/20 CCTV recording was physical abuse of the patient. FLN #1 should not have used physical force to get Patient #1 to swallow the medication. "This was a violation of the patient's rights." Immediately following counseling FLN #1 on the observed incident, NSS, LN #9 called the DON, who was the facility's Executive On-Call on 12/19/20. After informing the DON of the incident, the NSS, LN#9 stated it was decided to have FLN #1 return to the Chilkat Unit and work the remainder of the assigned shift. The only restriction was FLN #1 was not to have any contact with Patient #1 for the remainder of the shift.


Interview conducted on 6/30/21 at 1:45 pm, the DON revealed he/she did not recall receiving a call from the NSS, LN#9 on 12/19/20 regarding an allegation of abuse by LN #7. The DON denied instructing NSS. LN#9 to allow FLN #1 to work the remainder of the shift on the Chilkat Unit. During the interview, the DON stated that it is the policy of the facility that patients have the right to refuse to take medications. If a facility nurse forces a patient to take medications, and in absence of a court order, that would be physical abuse. The DON also stated that if an allegation of abuse is made, the accused staff member should immediately be removed from the area where the incident occurred and have no contact with the alleged victim pending the results of an internal investigation.

This deficiency was cited base on complaint # AK 047 and AK 974

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VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on policy review, record review, observations, and interviews, the hospital failed to ensure methods were employed for preventing and controlling the transmission of infections. Specifically, the hospital failed to ensure hand hygiene was performed in accordance with hospital policy during observations of a medication pass. The hospital failed to develop a policy and procedure for the staff to communicate the diagnosis, treatment, and lab test results when transferring patients to an acute care hospital. In addition, the hospital failed to ensure a patient was educated on the remaining timeframe required for quarantining, due to testing positive for Coronavirus (COVID-19) at the time of discharge for one (Patient #13) of three patients who tested positive for COVID-19 from a sample of 11 patients. These failures had the potential to affect all the 59 inpatients and any future patient admitted to the hospital.

Findings include:

1. Review of the hospital's policy titled "Hand Hygiene," effective 3/19/20, indicated "... All API personnel will practice hand hygiene:... Before and after contact with each client, his environment, and anything that comes in contact with the patient (even if gloves are worn); ... Before putting on gloves and immediately after removing them; Before putting on PPE (Personal protective Equipment) and immediately after removing; ... When preparing medication or preparing injectable medications; .... After touching trash/garbage, or biohazardous waste; . . . Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient; Change gloves during patient care if moving from a contaminated body site to a clean body site..."


Review of the hospital's policy titled "Standard Precautions," effective 3/19/20, indicated "... These precautions will be used in the care of all patients... Gloves must be worn for touching blood and body fluids, mucous membranes, or non-intact skin of all patients, and for handling items or surfaces soiled with blood or body fluids... Hand hygiene is performed before and after each patient contact, and between dirty and clean procedures. Hands and other skin surfaces should be washed immediately if contaminated with blood or body fluids. Hand hygiene is performed before donning gloves and immediately after gloves are removed. Alcohol hand sanitizers may be used instead of hand washing if the hands are not visibly dirty... Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, regardless of whether gloves are worn. Wash hands immediately after gloves are removed, between patient contacts, and when indicated to avoid transfer of microorganisms to other patients or environments. Wash hands between tasks and procedures on the same patient to prevent cross-contamination when necessary. . . Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items or environmental surfaces, before going to another patient, and wash hands immediately after care to avoid cross transmission of microorganisms..."


Observation on the Susitna Unit on 6/30/21 at 8:15 am revealed Licensed Nurse (LN) #5 administering medications to Patient #9. Observation revealed LN #5 dropped an Ativan (medication to treat anxiety disorders) 1 milligram (mg) pill on the floor and picked it up with his/her gloved hands. LN #5 then placed the Ativan pill in a paper medication cup and placed the cup in the narcotic drawer of the medication cart while still wearing the contaminated gloves. While wearing the same contaminated gloves, LN #5 opened another peel-packed Ativan pill and placed it in a paper medication cup, obtained a cup of water, and handed the water and Ativan pill to Patient #9. While wearing the same contaminated gloves, LN #5 threw the water cup and medication cup in the garbage can and proceeded to document on paper and the computer.


Continuous observation revealed on 6/30/21 at 8:33 am, LN #5, wearing the same contaminated gloves worn to administer Patient #9's medications, received a Nicotine patch that Patient #10 had removed from his/her left shoulder. While wearing the same contaminated gloves, LN #5 removed Ativan 1 mg from the narcotic drawer, and Depakote (medication to treat seizures) 1000 mg, Dulcosate (stool softener medication) 100 mg, Multivitamin 1000 mg, Vitamin D 4000 units, and Hydroxyzine (antihistamine medication) 50 mg from Patient #10's medication drawer. LN #5 opened each of the peel-packed medications, placed them in a paper medication cup, and gave the medications to Patient #10 with the same contaminated gloves. LN # 5 then removed his/her gloves and washed his/her hands.


In an interview on 6/30/21 at 9:00 am, LN #5 stated he/she is supposed to "don gloves and perform hand hygiene before and after patient contact and don gloves and change gloves preferably between patients." LN #5 stated he/she is supposed to perform hand hygiene "after removing gloves." After the surveyor reviewed the observations made during the medication pass LN #5 had with patient #9 and Patient #10, LN #5 confirmed the observations were breaches in infection control related to hand hygiene practice.


2. Review of hospital policy titled, "Standard Precautions," effective 3/19/20, "COVID-19 Testing," effective 11/13/20, "Pandemic Influenza Response," effective 3/24/20, and "Isolation Precaution," effective 5/10/21, indicated no policy addressed the process the staff was to implement to communicate the diagnosis, treatment, and lab test results when transferring patients to an acute care hospital.


In an interview on 7/1/21 at 11:00 am, the Infection Prevention Coordinator (IPC) stated that the hospital does not have a policy that addresses the process for communicating the diagnosis, treatment, and laboratory test results when transferring patients to an acute care hospital or other healthcare provider.


3. Review of the hospital policy titled "Pandemic Influenza Response," effective 3/24/20, indicated the policy did not address the process for educating patients who tested positive for COVID-19 about the timeframe for continuing quarantine once discharged .


Review of Patient #13's medical record, under the "Summary" tab, indicated Patient #13 was admitted on [DATE] and discharged on [DATE]. Further review indicated, under the "Diagnosis" tab, Patient #13's diagnoses included ...COVID-19.... Further review, under the "Laboratory" tab, indicated Patient #13 had a COVID-19 test collected on 2/1/21 that resulted positive on 2/1/21. Review of the " Psychiatric Discharge Summary," located under the "Notes" tab, indicated Patient #13 "... tested COVID negative prior to transfer to API [Alaska Psychiatric Institute], but was retested upon arrival (because her husband is COVID positive) and this time tested COVID positive... She will discharge back to her home in Anchorage, where she resides with her husband..." Review of Patient #13's "Social Work Discharge Summary" and the "Nurse Discharge Summary," both located under the "Notes" tab, indicated there was no documentation that Patient #13 was educated about the length of time he/she needed to remain in quarantine, since patient #13 was being discharged two days after having been tested positive for COVID-19.


In an interview on 7/1/21 at 11:00 am, the IPC stated a patient should be informed at discharge regarding the length of time the patient needed to remain in quarantine if it had not been at least 10 days since the positive COVID-19 result had been received.

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