HospitalInspections.org

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

482.13 Tag A-0144
The information reviewed during the survey provided evidence the facility failed to ensure a ligature resistant environment for a psychiatric hospital with locked patient care units and failed to assess and mitigate ligature risks on locked patient care units.

The findings were:

While touring the facility on September 16, 2020, an observation was made of six fire doors located in hallways on all patient units with an arm closure at the top of the doors creating a ligature point. The doors were left open due to patient bedrooms located on either side of the doorway. The ligature point was accessible to patients. The doors were not visible from the nurses' station.

It was also observed while touring the facility on September 16, 2020, there were numerous fire sprinklers uncovered and projecting from the ceiling, creating a ligature point on all patient care units. There were sprinkler covers not flush with the ceiling, creating a projection from the ceiling and a ligature point. The sprinklers were not in view of the nurses' station.

It was determined the facility failed to ensure a ligature resistant environment for psychiatric hospitals with locked patient care units and failed to assess and mitigate ligature risks on locked patient care units.

The Immediate Jeopardy Template was given to the facility at 2:15 PM on September 16, 2020.

The facility submitted an acceptable IJ Removal Plan at approximately 4:00 PM on September 16, 2020.

The IJ removal plan indicated the facility will undertake a comprehensive anti-ligature risk assessment consistent with best practice standards for all patient care areas to assure that no additional risks are present. Based upon the anti-ligature assessment the hospital will take necessary steps to mitigate the fire door closure risk and the sprinkler head risk by replacing the devices with acceptable replacement devices that meet the anti-ligature standards.

The facility immediately implemented seven-minute checks on areas where patients are left alone or with minimal supervision. The increase from 10-minute checks to seven-minute checks will remain in effect until ligature risks are mitigated. All staff will be trained immediately on the increase in observation levels. Charge nurses and nurse managers will monitor compliance with the increased observation levels.

Review of the facility Immediate Jeopardy removal plan revealed the facility addressed the Immediate Jeopardy.


Cross reference:
482.41 Physical Environment

Based on review of facility policy, observation and staff (EMP) interview it was determined the facility failed to ensure a safe physical environment was provided to all patients in seven of seven patient care modules (nursing units) observed.

Review on September 16, 2020, of the facility's policy, "Environmental Quality Inspection," last reviewed October 5, 2018, revealed "I. Policy Statement It is the policy of KidsPeace to place a high priority on maintaining safe, secure, comfortable, attractive and home-like facilities. II. Purpose The purpose of this policy and procedure is to ensure that there is a system for maintaining and improving the physical plant facilities of our programs. ... V. Policy... C. It is the responsibility of Program Leadership to ensure: I. Each Program Director is responsible to ensure that his or her center provides a clean, attractive and safe environment. a) Similarly, each House Manager and/or RN Supervisor has direct responsibility for their house's/module's environmental quality. b) Therefore each House Manager, RN Supervisor, or designee must conduct a monthly personal inspection of their program to detect problems with the physical plant. c) The following must be included as a part of the monthly inspection: d) Repairs and Maintenance Needs e) Aesthetics f) Safety g) Cleanliness..."

Observation during a tour of the SouthWest unit with EMP4 on September 14, 2020, at 1:50 PM revealed in patient room 223 black spots on the ceiling circling the motion sensor and smoke detector extending approximately two inches. Further tour in patient room 224 revealed two black spots on the ceiling and a strong mildew smell.

Interview with EMP4 on September 14, 2020, at 1:55 PM confirmed the findings of black spots on the ceiling of patient rooms 223 and 224 and the strong mildew smell.

Observation during a tour on September 15, 2020, at 8:35 AM of the main entrance to the hospital contained a water stain approximately twelve inches by six inches and black dust hanging on the two air vents on the facade that extends down from the ceiling in the main entrance waiting area.

Tour with EMP3 of the main entrance area on September 15, 2020, at 12:15 PM confirmed the presence of the water stain and dusty air vents in the main hospital entrance waiting area.

Observations during a tour of the south building with EMP6 on September 15, 2020, from approximately 1:00 PM until 2:30 PM, included damage to the ceilings in the Southlink (corridor linking the Southeast and Southwest modules) safe room, the Southlink conference room, the Southwest safe room and the Southeast safe room. Damage to the Southlink safe room included an approximately 18-inch by 18-inch area missing chunks of ceiling material. Adjacent to that area was an approximately nine-inch by nine-inch water stain. The Southlink conference room had an area of the ceiling with a water stain. The ceiling material of the Southwest conference room was degraded with multiple chipped/missing material. The Southeast safe room had a ceiling mounted intercom speaker hanging by a screw. When EMP6 attempted to secure the speaker, it fell to the floor.

Interview with EMP6 on September 15, 2020, during the 1:00 PM to 2:30 PM tour confirmed the above findings.


Cross Reference:
482.13 - Condition -Patient Rights

Based on the systemic nature of the standard-level deficiencies related to Infection Control, it was determined the hospital failed to substantially comply with this Condition.

Findings include:

The following standards were cited and show a systemic nature of non-compliance with regards to Infection Control as follows:

(482.42(a) Tag A-0748)
The information reviewed during the survey provided evidence that the facility failed to have an Infection Control Coordinator in place who was qualified by experience, ongoing education or specialized training in infection control.

(482.42(a)(1) Tag A-0749)
The information reviewed during the survey provided evidence that the facility failed to properly screen visitors for communicable disease (COVID-19) according to facility screening protocols; and the facility failed to follow infection control policies ensuring there was an approved infection control risk assessment (ICRA) form documented prior to the start of a renovation project, failed to monitor the ICRA barrier, and failed to maintain an adequate ICRA barrier.

Based on review of facility documents, observations, and staff interview (EMP), it was determined the facility failed to ensure a ligature resistant environment for a psychiatric hospital with locked patient care units and failed to assess and mitigate ligature risks on locked patient care units.

Review on September 16, 2020, of the facility's policy, "Protecting Client's Rights and Responsibilities," last reviewed May 9, 2017, revealed "... IV. General ... Client's Rights 1. You have the right to safe, considerate, respectful care and to expect reasonable continuity of this care. ..."

Review on September 16, 2020, of the facility's policy, "Environmental Quality Inspection," last reviewed October 5, 2018, revealed "I. Policy Statement It is the policy of KidsPeace to place a high priority on maintaining safe, secure, comfortable, attractive and home-like facilities. II. Purpose The purpose of this policy and procedure is to ensure that there is a system for maintaining and improving the physical plant facilities of our programs. ... V. Policy ... C. It is the responsibility of Program Leadership to ensure: I. Each Program Director is responsible to ensure that his or her center provides a clean, attractive and safe environment. a) Similarly, each House Manager and/or RN Supervisor has direct responsibility for their house's/module's environmental quality. b) Therefore each House Manager, RN Supervisor, or designee must conduct a monthly personal inspection of their program to detect problems with the physical plant. c) The following must be included as a part of the monthly inspection: d) Repairs and Maintenance Needs e) Aesthetics f) Safety g) Cleanliness ..."

Review on September 16, 2020, of the facility document, "Hospital Operations Physical Plant Check," no date of last review, revealed ligature risks were not assessed.

Interview on September 16, 2020, with EMP2, at approximately 10:00 AM, confirmed ligature risks were not assessed on the Hospital Operations Physical Plant Check. EMP2 revealed the facility did not have a policy related to ligature risk assessment, there was no anti-ligature plan, and the facility did not complete ligature risk assessments.

Observation on September 16, 2020, at approximately 11:00 AM, of the Southwest Module, revealed a set of fire doors located in the hallway of the patient unit with an arm closure at the top of the doors creating a ligature point. The doors were left open due to patient bedrooms located on either side of the doorway. The ligature point was accessible to patients. The doors were not visible from the nurses' station.

It was observed there were numerous fire sprinklers uncovered and projecting from the ceiling, creating a ligature point in the dining room on the patient care unit. There were sprinkler covers not flush with the ceiling, creating a projection from the ceiling and a ligature point located in the hallways of the patient care units approximately every 10-15 feet. The sprinklers were not in view of the nurses' station.

Interview on September 16, 2020, with EMP2, at approximately 11:05 AM, confirmed the fire door arm closure created a ligature point and the sprinklers created a ligature point. EMP2 confirmed both were not visible by the nurses' station.

Observation on September 16, 2020, at approximately 11:15 AM, of the Southeast Module, revealed a set of fire doors located in the hallway of the patient unit with an arm closure at the top of the doors creating a ligature point. The doors were left open due to patient bedrooms located on either side of the doorway. The ligature point was accessible to patients. The doors were not visible from the nurses' station.

It was also observed there were numerous fire sprinklers uncovered and projecting from the ceiling, creating a ligature point in the dining room on the patient care unit. There were sprinkler covers not flush with the ceiling, creating a projection from the ceiling and a ligature point located in the hallways of the patient care units approximately every 10-15 feet. The sprinklers were not in view of the nurses' station.

Interview on September 16, 2020, with EMP2, at approximately 11:20 AM, confirmed the fire door arm closure created a ligature point and the sprinklers created a ligature point. EMP2 confirmed both were not visible by the nurses' station.

Observation on September 16, 2020, at approximately 11:30 AM, of the Lower Level Central Module, revealed a set of fire doors located in the hallway of the patient unit with an arm closure at the top of the doors creating a ligature point. The doors were left open due to patient bedrooms located on either side of the doorway. The ligature point was accessible to patients. The doors were not visible from the nurses' station.

It was also observed there were sprinkler covers not flush with the ceiling, creating a projection from the ceiling and a ligature point located in the hallways and dining room of the patient care units. The sprinklers were not in view of the nurses' station.

Interview on September 16, 2020, with EMP2, at approximately 11:35 AM, confirmed the fire door arm closure created a ligature point and the sprinklers created a ligature point. EMP2 confirmed both were not visible by the nurses' station.

Observation on September 16, 2020, at approximately 11:45 AM, of the Northeast Module, revealed a set of fire doors located in the hallway of the patient unit with an arm closure at the top of the doors creating a ligature point. The doors were left open due to patient bedrooms located on either side of the doorway. The ligature point was accessible to patients. The doors were not visible from the nurses' station.

It was also observed there were numerous fire sprinklers uncovered and projecting from the ceiling, creating a ligature point in the dining room on the patient care unit. There were sprinkler covers not flush with the ceiling, creating a projection from the ceiling and a ligature point located in the hallways of the patient care units approximately every 10-15 feet. The sprinklers were not in view of the nurses' station.

Interview on September 16, 2020, with EMP2, at approximately 11:50 AM, confirmed the fire door arm closure created a ligature point and the sprinklers created a ligature point. EMP2 confirmed both were not visible by the nurses' station.

Observation on September 16, 2020, at approximately 12:00 PM, of the Northwest Module, revealed a set of fire doors located in the hallway of the patient unit with an arm closure at the top of the doors creating a ligature point. The doors were left open due to patient bedrooms located on either side of the doorway. The ligature point was accessible to patients. The doors were not visible from the nurses' station.

It was also observed there were numerous fire sprinklers uncovered and projecting from the ceiling, creating a ligature point in the dining room on the patient care unit. There were sprinkler covers not flush with the ceiling, creating a projection from the ceiling and a ligature point located in the hallways of the patient care units approximately every 10-15 feet. The sprinklers were not in view of the nurses' station.

Interview on September 16, 2020, with EMP2, at approximately 12:05 PM, confirmed the fire door arm closure created a ligature point and the sprinklers created a ligature point. EMP2 confirmed both were not visible by the nurses' station.

Observation on September 16, 2020, at approximately 12:15 PM, of the Lower Level North Module, revealed a set of fire doors located in the hallway of the patient unit with an arm closure at the top of the doors creating a ligature point. The doors were left open due to patient bedrooms located on either side of the doorway. The ligature point was accessible to patients. The doors were not visible from the nurses' station.

It was also observed there were sprinkler covers not flush with the ceiling, creating a projection from the ceiling and a ligature point located in the hallways and dining room of the patient care units. The sprinklers were not in view of the nurses' station.

Interview on September 16, 2020, with EMP2, at approximately 12:20 PM, confirmed the fire door arm closure created a ligature point and the sprinklers created a ligature point. EMP2 confirmed both were not visible by the nurses' station.

Based on facility documents, observation and staff (EMP) interview(s), it was determined the facility failed to ensure refrigerator/freezer temperature(s) were monitored daily, refrigerator/freezer temperature(s) were in range daily and all foods stored in the refrigerator was labeled and dated with an expiration date.

Findings include:

Review on September 15, 2020, of facility policy, "Food Storage," last reviewed July 11, 2017, revealed "I. Policy Statement It is the policy of [facility] to assure safety and sanitation by storing food appropriately. ... V. Policy A. Proper Food Storage 1. All foods stored in the refrigerator or freezer shall be covered, labeled, and dated. ... 10. All leftover foods shall be covered, labeled, and dated, indicating both what it is and when it was cooked, and used within 72 hours. ..."

Review on September 15, 2020, of facility policy, "Monitoring Kitchen Refrigeration Temperatures," last reviewed April 17, 2019, revealed "A. Applies to: 1. All employees working in food services including cooks and servers. ... B. 1. Temperature tracking sheets are posted in all locations on or around the equipment. ... It is the food service worker's responsibility to track the temperatures of each refrigerator on the log daily. ... 2, Refrigerators need to be holding food between (should be 33-41) degrees farenheit and freezers need to be holding food between -10 and 0 degrees farenheit. ... 3, Food service employees will track the temperature on the chart provided, If they find that the temperature of the equipment is out of range they should first determine if the equipment is not functioning properly or if it is in a defrost cycle. To check this they should re-check the temperature within an hour, if the refrigerator is still out of compliance, the employee will need to contact the emergency maintenance number. The employee must also remove the product from the refrigeration, once removed the food service worker will temp the products. If the products are warmer than 41 degrees farenheit they need to be discarded, Any equipment out of compliance needs to be reported to a supervisor immediately..."

Observation on September 15, 2020, at 9:20 AM, revealed September 2020 facility refrigerator/freezer temperature record sheets with numerous blanks.

Interview with EMP5, on September 15, 2020, at 9:20 AM, confirmed the September 2020 facility refrigerator/freezer temperature record sheets with numerous blanks. EMP5 confirmed the kitchen staff are to check and record the refrigerators and freezer temperatures daily and the milk coolers two times a day.

Review on September 15, 2020, at 10 :50 AM, of facility refrigerator/freezer temperature record sheets revealed no documentation noted of temperatures for kitchen #1 refrigerator on January 16 and 31, 2020, March 14, 23 and 31, 2020, April 8-9, 10, 15, 17, 18, 19, 21-23, 26, 27, 29 and 30, 2020 and July 17 and 28, 2020, kitchen #2 refrigerator on January 9, 16 and 31, 2020, February 24, 2020, March 14 and 31, 2020, May 16, 17 and 28, 2020 and July 8-10, 15, 17-19, 21-23, 26, 27, 29, 30 and 31, 2020, Athlete fridge on May 8-10 , 15, 17-19, 21, 22-24, 26, 27, 29, 30 and 31, 2020 and August 8, 2020, 1 door refrigerator on June 6, 14, 17, 18 and 28, 2020 and July 4, 8-10, 12, 17, 18, 21, 28 and 31, 2020, freezer on September 3 and 13, 2020 and milk cooler #3 on January 3, 4, 8, 9, 13-16, 20, 24 and 31, 2020, February 1, 5, 10, 27 and 28, 2020, March 6, 9, 12-14, 20, 22, 23, 25, 27-29 and 31, 2020, May 1, 4, 8-23, 25-31, 2020, June 9, 15, 17, 18, 20- 22, 24, 26, 29 and 30, 2020 and July 15-18, 20-22, 24, 27, 28, 30 and 31, 2020.

Interview with EMP7, on September 15, 2020, at 11:05 AM, confirmed the facility refrigerator and freezer temperature record sheets, for 2020, with no temperatures documented on numerous days throughout the year. EMP7 confirmed the kitchen staff are aware they are to check the refrigerator and freezer and milk cooler(s) temperatures daily.

Observation on September 15, 2020, at 9:25 AM, revealed the refrigerator/freezer temperature record sheet with the freezer temperature above out of range on September 13, 2020, with a temperature of 1 degree and September 14, 2020 with a temperature of 1 degree. No documentation noted what was done concerning the out of range temperature.

Interview with EMP5, on September 15, 2020, at 9:25 AM, confirmed the refrigerator/freezer temperature record sheet with the freezer temperature above out of range on September 13, 2020 with a temperature of 1 degree and September 14, 2020 with a temperature of 1 degree. EMP5 confirmed there was no documentation noted what was done concerning the out of range temperature. EMP5 confirmed the kitchen staff are to notify their supervisor if a temperature is out of range.

Review on September 15, 2020, at 11:00 AM, of facility refrigerator/freezer temperature record sheets revealed kitchen #1 refrigerator with above out of range temperatures on January 1, 10, 14, 15, 18, 20, 27 and 29 and milk cooler #3 with below out of range temperatures on January 1, 3, 4, 12-15, 17, 22, 23 and 27, 2020, February 2, 5 and 14, 2020, March 2, 13, 19, 21, 25, 28 and 30, 2020, May 3, 7, 11-13, 16, 20, 24, 25 and 28, 2020, June 4-8, 10, 12, 15, 21, 22, 25, 26 and 30, 2020 and July 20, 2020. Continued review revealed no documentation noted what was done concerning the above or below out of range temperatures. Are these out of range freezer temps?

Interview with EMP7, on September 15, 2020, at 11:10 AM, confirmed the refrigerator/freezer temperature record sheets, for 2020, with numerous temperatures out of range and no documentation noting what was done when an out of range temperature occurred. EMP7 confirmed when a temperature is found to be over or under the temperature range, the kitchen staff are to check to see why it is out of range; i.e. was a door left open, were items being added or removed, ... EMP7 confirmed the kitchen staff are to make a note of what was done; i.e. maintenance made aware, ...

Interview with EMP5, on September 15, 2020, at 11:15 AM, confirmed the kitchen staff are to document on a sheet when a temperature is above or below the range and what was done about the out of range temperature at that time.

Observation on September 15, 2020, at 9:35 AM through 9:50 AM, revealed a foam container of enchiladas dated September 14, 2020, a foam container of cooked ground beef dated September 14, 2020, six plastic containers of pineapples, with two, dated September 12, 2020, a plastic container of pickles and a plastic bag of gluten-free rolls with no date documented, in the refrigerators, with no expiration date documented. Are the dated ones ok? The policy states the date cooked should be on the container and the food used within 72 hours.

Interview with EMP5, on September 15, 2020, at 9:40 AM, confirmed there was no expiration date on a foam container of enchiladas dated September 14, 2020, a foam container of cooked ground beef dated September 14, 2020, six plastic containers of pineapples, with two dated September 12, 2020, a plastic container of pickles and a plastic bag of gluten-free rolls with no date documented, in the refrigerators. EMP5 confirmed the items are to have documentation of the date the item was prepared or the date of the leftover's placement in a foam container and an expiration date of 72 hours on the container.

Based on facility documents, observation and staff (EMP) interview, it was determined the facility failed to ensure the emergency crash cart equipment was monitored daily on the North and South carts.

Findings include:

Review on September 16, 2020, of facility policy "Emergency Equipment Monitoring," last reviewed May 6, 2019, revealed "I. Policy Statement Emergency equipment will be monitored nightly by the Night Nurse Manager or designee. II. Purpose To ensure accessibility and proper working order for all emergency medical equipment. ... V. Policy A. Emergency Equipment ... 2. Night Nurse manager or designee will check all emergency equipment on the north side and south side crash carts to assure proper working order, expiration dates, volume level, etc. 3. Night Nurse Manager or designee will complete Emergency Equipment Checklist kept on each respective crash cart nightly, during the 11 PM-7AM shift. a. Nurse's initials will be written in appropriate boxes on the checklist under the corresponding date of the month. The initials indicate verification that each item or piece of equipment is present and in working order. .... "

Observation on September 15, 2020, at 10:30 AM, revealed September 2020 facility Emergency Equipment QA checklist with numerous blanks.

Interview with EMP8, on September 15, 2020, at 10:35 AM, confirmed the September 2020 facility Emergency Equipment QA checklist with numerous blanks. EMP5 confirmed the night nurse manager is responsible for checking the North and South crash carts daily.

Review on September 16, 2020, of facility Emergency Equipment QA record checklists revealed no documentation noted of the North side crash cart check on April 18, 20 and 22, 2019, May 10, 2019, June 2, 4, 7, 8, 11, 12, 17, 19 and 20, 2019, July 1, 4, 5 and 19, 2019, August 6-8, 11-13 and 20, 2019, December 25, 2019, January 31, 2020, March 7 and 31, 2020, April 4, 7, 8, 14-17, 24 and 30, 2020, May 1, 12, 13, 19, 20, and 26, 2020, June 8, 2020, and July 24, 2020 and of the South side crash cart check on April 22, 2019, May 18-20, 2019, June 2, 4, 7, 8, 11, 12, 17, 19 and 20, 2019, July 1, 5, 19 and 29, 2019, August 6-8, 12, 13, 19 and 20, 2019, September 10, 2019, December 25, 2019, March 7, 24, 25 and 31, 2020, April 4, 7, 8, 14-17, 24 and 30, 2020,May 1, 12, 13, 19, 20 and 26, 2020, June 8, 2020 and July 24, 2020.

Interview with EMP8, on September 16, 2020, at approximately 11:30 AM, confirmed the Emergency Equipment QA checklists, for 2019 and 2020, with no initials documented on numerous days throughout the past year and this year and confirmed the cart was not checked. EMP8 confirmed the night shift nurse manager was aware that they are to check the crash carts daily.

Based on review of facility documents, review of personnel file (PF) and interview with staff (EMP), it was determined the facility failed to ensure that the designated infection control officer had experience, ongoing education or specialized training in infection control, other than the basic infection control required by facility staff.

Findings include:

Review on September 16, 2020, at 4:45 PM, of the written job description for the Infection Control Coordinator revealed, "Qualifications (Education, Training and Experiences) ... 3. Training and experience in Infection Control preferred 4. Maintains at least 10 CEU's (Continuing Education Credits) directly related to Infection Control annually ... "

Review on September 15, 2020, at 9:00 AM, of PF3 revealed no documentation of experience, specialized training, or ongoing training in infection control other than the basic infection control required by facility staff. There was no documentation of at least 10 CEU's of Infection Control training. There was no signed job description in PF3 outlining job responsibilities for the Infection Prevention role.

Interview with EMP3 on September 15, 2020, at 11:20 AM confirmed EMP3 was the designated infection control nurse since July 2020. Further interview with EMP3 confirmed that EMP3 did not have experience, specialized training or ongoing education in infection control other than what was required by facility staff.

Based on observational tour, review of facility documents and interview with staff (EMP), it was determined the facility failed to properly screen visitors for communicable disease COVID-19 according to facility screening protocols; failed to follow infection control policies ensuring there was an approved infection control risk assessment (ICRA) form documented prior to the start of a renovation project; failed to monitor the ICRA barrier and failed to maintain an adequate ICRA barrier.

Findings include:

On arrival to facility on September 14, 2020, at 10:15 AM, the attendant took Visitor1's temperature but did not ask any COVID-19 screening questions. On September 15, 2020, at 8:30 AM, the attendant took Visitor1, Visitor 2 and Visitor 3's temperature but did not ask any COVID-19 screening questions. On September 16, 2020, at 8:30 AM, the attendant took Visitor1's temperature but did not ask any COVID-19 screening questions.

On arrival to facility on September 14, 2020, at 10:00 AM, the attendant took Visitor 4's temperature but did not ask any COVID-19 screening questions. On September 15, 2020, at 9:00, the attendant took Visitor 4's temperature but did not ask any COVID-19 screening questions. On September 16, 2020, at 9:00 AM, the attendant took Visitor 4's temperature but did not ask any COVID-19 screening questions.

Interview with EMP3 on September 15, 2020 at 10:20 AM stated that the attendants at the gated entrance to the facility are supposed to screen any visitor or associate for COVID-19 by taking their temperature and using the screening form. Requested the screening form.

Review of the facility's "Welcome Center- Associate Illness Screening" form provided by EMP3 on September 15, 2020, contained listing of "Associate ID#, Associate name, temperature, new cough, short of breath, chills, new muscle pain, sore throat, new loss of taste or smell, other symptoms, Have you taken any pain relievers or fever reducers within the last 4 hours? Ibuprofen (Motrin, Advil) NSAID's (Aleve, Naproxen, Naprosyn) Acetaminophen (Tylenol) Were you in contact with someone diagnosed with COVID-19 that you are aware of? Was the associate sent home due to temperature and/or other symptoms?"

Further interview with EMP3 on September 15, 2020, at approximately 10:40 AM confirmed the attendants should have temperature screened and asked the questions provided on the associate illness screening with any visitor or associate.

Review of facility policy "Infection Prevention in Construction, Renovation and Maintenance," effective date September 11, 2019, revealed "I. ... It is the policy of KidsPeace to describe guidelines to be followed during all phases of ... renovation and construction at the Hospital in an effort to provide clients, associates and visitors with an environment that is safe from potential infections. ... IV. ... Definitions of construction activity: Type A Building upkeep, inspections and non-invasive activities. Includes but is not limited to removal of ceiling tiles... painting (but not sanding) wall covering, electrical trim work, minor plumbing and activities which do not generate dust or require cutting of walls... Type B Small scale, short duration activities, which create minimal dust. Includes, but is not limited to, installation of ... cabling, access to chase spaces, drilling of walls or ceilings where dust migration can be controlled. Type C Any work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies. Includes, but is not limited to, sanding of wall for painting or wall covering, removal of floor coverings, wall paper, baseboards, ceiling tiles and casework, new wall construction, minor ductwork or electrical work above ceilings, major cabling activities, and any activity which cannot be completed within a single work shift. Type D Major demolition and construction projects. Includes, but is not limited to, activities which require heavy demolition or removal of walls, ceiling system, new construction, and consecutive work shifts. Definitions of patient Risk Group: Group I Office areas not adjacent to patient areas, Environmental Services, Engineering areas, Vacant patient areas. Group II Patient Occupied Care Areas... Classrooms, Admission Areas, Cafeteria, Storage Rooms. ... Definitions of Infection Prevention Procedures: CLASS I 1. Obtain approval from supervisor to perform the work at a specified time. 2. Isolate the area of activity from patients. 3. Close all doors if possible; if doors cannot be closed, restrict patient traffic through work site. 4. Ceiling tiles should be replaced as soon as possible. 5. Wipe surfaces within work site with disinfectant at completion of job. Class II 1. Obtain approval from supervisor to perform the work at a specified time. 2. Erect plastic barriers or hard barriers. 3. Isolate and seal HVAC system return air duct in area where work is being performed. 4. Contain construction waste before transport in tightly covered containers with non-porous covers. 5. Vacuum all surfaces or wet mop periodically and at completion of project to reduce dust. 6. Wipe surfaces within work site with disinfectant at completion of job. Class III 1. Obtain infection control approval and approval from area supervisor before construction begins. 2. Isolate and seal HVAC return air duct system in area where work is being done. 3. Install required barriers before construction begins. 4. Provide sticky walk-off mats at entrance to work area. Mats are to be replaced as needed throughout the workday. 5. Any areas, which show evidence of mold or fungal growth, must be evaluated by Infection Prevention to determine removal protocol. 6. Transport construction waste in tightly covered containers. If carts are used, the wheels should be wet-wiped with disinfectant before leaving the work site. 7. The work area shall be maintained reasonably clean and free of accumulations of dust and debris. 8 Vacuum work area and wipe all vertical and horizontal surfaces with disinfectant before removing barriers. 9. Run water for at least 15 minutes from any lines in which water service has been interrupted and/or new additional lines installed during activities off of main feeds. 10. Thoroughly clean inside barrier then remove barrier materials carefully in a manner that prevents dust dispersal. 11. Repeat cleaning process of wiping all vertical and horizontal surfaces with disinfectant and vacuum area after barriers are removed. Class IV 1. Obtain infection control approval and approval from area supervisor before construction begins. 2. Isolate and seal HVAC return air duct system in area where work is being done. 3. Install required barriers before construction begins. 4. Seal holes, pipes, conduits, and punctures appropriately. 5. The work area shall be maintained clean and free of accumulation of dust and debris. 6. Contractors are required to comply with pre-determined traffic patterns. 7. Provide stick walk-off mats at entrance to work area. Mats are to be replaced as needed throughout the work day. 8. Maintain an egress free of dirt/debris through use of vacuum cleaner or wet mop with frequently changed water. 9. Transport construction waste in tightly covered containers with non-porous covers (i.e. no linen) If carts are used, the wheels should be wet-wiped with disinfectant before leaving the work site. 10. Vacuum work areas with vacuums and wipe all vertical and horizontal surfaces with disinfectant before removing barriers. 11. Run water for at least 15 minutes from any lines in which water service has been interrupted and/or new additional lines installed during activities off of main feeds. 12. Thoroughly clean inside barrier then remove barrier material sin a manner that prevents dust dispersal. 13, Repeat cleaning process of wiping all vertical and horizontal surfaces with disinfectant and vacuum area with vacuum after barriers are removed. V. Policy A. The Infection Control Risk Assessment (ICRA) will be completed by the Infection Control Officer and the Director of Pennsylvania Operations or designee. ... E. Operations informs Infection Prevention of planned construction projects, facelifts and/or enhancement projects within the system and plans and implements infection-preventative actions. Operations is also responsible for informing all Contractors of this policy and ensuring their adherence to this policy. ... G. The Infection Control Officer: advises on interventions to limit infection risk during construction and maintenance projects. Ensures that major infection control components are addressed as appropriate and justified by relevant guidelines and standards. ... E. The Hospital Infection Control Officer will document all ICRA forms in committee minutes to demonstrate compliance with the policy. ..."

Observational tour with EMP4 on September 14, 2020, at 12:00 PM revealed an ICRA barrier over a doorway in the connecting hallway leading to the South units which contained approximately a foot of the plastic sheeting with tape unsecured on the left upper corner and left side of the barrier tape was unsecured approximately four feet in length and gaping open. Observation revealed the ICRA barrier was over a roughly cut opening in the wall.

Interview with EMP4 on September 14, 2020, at 12:00 PM confirmed it was a construction project and that the plastic sheeting was not intact but did not know the details of the construction project.

Observational tour with EMP6 on September 15, 2020, at 1:00 PM revealed plastic sheeting over a large doorway in the connecting hallway leading to the South units. The plastic was secured with tape at the top only. Behind the plastic to the right was a newly installed door.

Interview with EMP6 on September 15, 2020 at 1:00 PM revealed there was a construction project to widen the doorway for the purpose of installing a new electronic medicine dispensing system in the area. EMP6 confirmed the plastic sheeting was not intact and s/he was unaware of a monitoring process for the ICRA barrier.

Review of the Infection Control Risk Assessment provided by EMP3 on September 15, 2020, at approximately 11:20 AM revealed the project description was a Passport Medicine Machine Installation. Replace existing door and prep room. The project start date was on September 9, 2020. The Infection Control Risk Assessment/Construction form was not completed until September 15, 2020. The project was listed as Type B, Group I, Class I, which did not follow the Class type and infection prevention instructions according to the policy description.

Interview with EMP3 on September 15, 2020, at approximately 11:20 AM confirmed the ICRA barrier was not intact. Further interview with EMP3 confirmed that the facility did not document an infection control risk assessment prior to the start of the project or complete or document periodic monitoring to ensure the ICRA Infection Prevention interventions were adhered to throughout the project.