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Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure the patient's right to care in a safe setting and notification of patients of their rights.

Findings include:

1. The facility failed to ensure 1:1 observation is maintained for all patients with a physician's order for 1:1 supervision (Cross refer to Tag 144).

2. The facility failed to ensure appropriate patient monitoring and failed to implement and follow its policy and procedure regarding safeguarding equipment monitoring. (Cross refer to Tag 144).

3. The facility failed to ensure that a summary of Patient Rights is posted conspicuously in public places (Cross refer to Tag 116).

Based on observation, staff interviews, review of nationally recognized guidelines, review of personnel files, and review of facility documents, it was determined that the facility failed to ensure infection control practices to mitigate the spread of COVID-19.

Findings include:

1. The facility failed to adhere to appropriate infection control standards and failed to ensure policies and procedures addressed PPE usage, when caring for patients positive for COVID-19. (Cross refer to Tag 749).

2. The facility failed to ensure staff adhered to appropriate standards of use for PPE and failed to ensure staff followed policy and procedure regarding isolation precautions (Cross refer to Tag 749).

3. The facility failed to adhere to CDC guidance regarding infection control practices used to mitigate the spread of COVID-19 (Cross refer to Tag 749).

5. The facility failed to ensure that staff education and training, regarding COVID-19, in accordance with policies and procedures and CDC guidance, is conducted (Cross refer to Tag 775).

Based on observation and staff interview, it was determined that the facility failed to ensure Patient Rights is posted conspicuously in patient rooms and in public places throughout the hospital.

Findings include:

1. During a tour of the facility on 8/7/2020 at 10:25 AM, in the presence of Staff #1, Patient Rights were not conspicuously posted in patient rooms or on the following units:

a. The Yellow Zone

b. The Green Zone

c. The Red Zone

2. Staff #1, Staff #4 and Staff #23 confirmed the above findings.

A. Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure one-to-one (1:1) observation is maintained for all patients with a physician's order for 1:1 supervision.

Findings include:

Reference: Facility document, "1:1 PCA Coverage" states, "... It is the policy of [name of facility] that 1:1 PCA coverage will be provided for any patient requiring constant monitoring due to unstable medical, behavioral or psychological issues... Procedure... 2. The physician will decide that there is a need for 1:1 coverage and write the order... 4. A request for PCA services will be referred to the PCA Supervisor assigned to the unit, or the Supervisor in charge. ... 5. The PCA Supervisor and the PCA staff will be informed as to the reason for the 1:1 supervision along with observations or precautions required. All long term 1:1 orders are reviewed at the quarterly safeguarding meetings on each unit to assess their continued need."

1. During an investigation of State Complaint #NJ00135758 conducted on 8/5/20, the following was observed:

a. A tour of the Red Zone was conducted on 8/5/20 at 12:05 PM. Staff #3 indicated Patient #3, in Room #563, was on 1:1 observation for "behavioral issues."

b. Staff #3 entered Room #563 to see if the PCA (patient care assistant), performing the 1:1, was able to be interviewed. There was no PCA present in the room, at that time, supervising the patient. Staff #3 walked through the room and confirmed that there was no PCA in the room. Staff #3 immediately left to find a staff member while this surveyor remained with the patient. Staff #3 returned with Staff #8 (PCA).

c. Upon interview at 12:10 PM, Staff #8 stated he/she was performing 1:1 observation for Patient #3. Staff #8 stated he/she left the patient because "I went to Room #542 to help clean up the patient. I just left [Patient #3] in the room to quickly go."

(i) Staff #8 was asked if he/she was told to leave Patient #3 and go to Room #542 to assist in cleaning up the patient. He/she stated, "It was already on the schedule. Today is the first time I had to leave the patient because [Patient #3] used to be in Room #542. He/she was just moved into Room #563 today."

d. Upon interview at 12:15 PM, Staff #11 stated that he/she was caring for Patient #3. He/she stated that the patient "only needed to be on 1:1 if he/she was in a wheelchair. When the patient is in the comfy chair, they don't need a 1:1 because they can't wheel around and be aggressive. The doctor started this because of the pandemic."

(i) A request was made to Staff #11 for the physician's order indicating that the patient could discontinue 1:1 observation when in the comfy chair. No order was provided.

e. Upon interview at 1:40 PM, Staff #9 stated that Staff #10 spoke to Staff #8 this morning and informed him/her that he/she would have to do a 1:2 instead of a 1:1 because PCAs were short-staffed. Staff #9 stated, "Staff #8 did not inform anyone that he/she was leaving the patient in Room #563 - usually when you leave as a 1:1 you have to make sure you have relief. This assignment should not have happened. The patient in Room #563 is a 1:1 and the assignment should not have been split. Room #542 should have been split between PCAs on that floor that were not doing 1:1s."

f. Upon interview at 2:05 PM, Staff #10 confirmed that he/she told Staff #8 that he/she was also assigned to the patient in Room #542 because "both patients were contagious." Staff #10 confirmed that he/she was aware that Patient #3 was on 1:1 observation. Staff #10 stated, "I told [Staff #8] that I would come and check to see if he/she needed help and sit with the patient. I didn't know he/she left the patient unattended."

g. Staff #10 was asked if he/she checked on Staff #8 during the shift to see if he/she needed help. Staff #10 stated, "No."

2. Review of Patient #3's medical record revealed a physician's order, signed and dated by the physician on 7/24/20, that states, "1:1 PCA Supervision at all times while awake for safety."

a. There was no evidence in the medical record of a physician's order indicating that Patient #3's 1:1 order was changed or discontinued.

3. Staff #1, Staff #3, and Staff #4 confirmed the above findings.

4. The facility provided an immediate action plan on 8/5/20, indicating that Nursing and PCA staff present on 8/5/20, would be immediately re-educated to the facility's 1:1 policy. The action plan indicated that Nursing and PCA staff that were not present on 8/5/20, would be re-educated on the facility's 1:1 policy prior to their next work day. The action plan also stated that Nursing Supervisors or their designees, will monitor all 1:1 assignments to ensure adherence to the facility's 1:1 policy.

5. During a tour of the Green Zone on 8/7/20 at 11:05 AM, the following was indicated:

a. Patient #9, located in Room #263, was identified as a patient on 1:1 observation. Staff #21 was observed in Room #263 with Patient #9 and Patient #17.

b. Upon interview at 11:10 AM, Staff #21 confirmed that he/she was performing 1:1 observation for Patient #9, but that he/she was also caring for Patient #17. Staff #21 stated, "Patient #9 is not on a strict 1:1, so I'm allowed to watch his/her roommate too."

c. Upon interview at 11:15 AM, Staff #14 stated that Staff #21 was correct and that Patient #9 was not a "strict 1:1."

d. Review of Patient #9's medical record revealed a physician's order, signed and dated by the physician on 7/23/20 at 8:00 AM, that stated, "1:1 PCA Supervision 7-3 and 3-11 shifts, On weekends and Off Program." Staff #1 and Staff #14 confirmed that "Off Program" means when the patient is not in school. Currently, school is not in session due to COVID-19.

6. During a tour of the Yellow Zone on 8/7/20 at 10:25 AM, Staff #24 was observed performing 1:1 observation for Patient #19 in Room #318. Upon interview at 10:30 AM, Staff #24 confirmed he/she did not receive re-education regarding the facility's 1:1 policy, as indicated in the facility's action plan.

a. Review of in-service records, on 8/7/20, lacked evidence that Staff #24 received re-education on the facility's 1:1 policy.

7. During a tour of the Green Zone on 8/7/20 at 11:05 AM, Staff #25 was observed performing 1:1 observation for Patient #18 in Room #250. Upon interview at 11:20 AM, Staff #25 confirmed that he/she did not receive re-education regarding the facility's 1:1 policy, as indicated in the facility's action plan.

a. Review of in-service records on 8/7/20 lacked evidence that Staff #25 received re-education on the facility's 1:1 policy.

8. An immediate jeopardy (IJ) was identified on 8/7/20 based on the above findings and the facility was notified on 8/7/20 at 2:42 PM.

a. An acceptable removal plan was received on 8/7/20.

An IJ removal visit was conducted on 8/25/20. During the onsite visit, the following was conducted: A tour of the Green, Yellow, and Red Zones, staff interviews, and review of staff education and training. It was determined the facility was in compliance with its IJ removal plan and the IJ was removed.


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B. Based on review of two (2) of three (3) medical records, staff interviews, and review of facility policy and procedure, it was determined that the facility failed to ensure the appropriate monitoring of the patient and failed to follow its policy and procedure regarding safeguarding equipment monitoring.

Findings include:

Reference: Facility policy, "Safeguarding Equipment Monitoring" states, "Purpose: All patients using safeguarding equipment utilized while in a wheelchair and in bed will be monitored regularly. ... Procedure... 1. PCA's assigned to each patient with safeguarding equipment are responsible for conducting checks of the patient's equipment every two hours while in bed... 5. The PCA will document their observations on the individual patient's "Safety Monitoring Sheet."... If all equipment is okay, they will initial the Safety Monitoring Sheet after each equipment check."

1. Review of Medical Record #15 on 8/7/2020 revealed the following:

a. The Physician's Order Sheet dated 7/24/20 states, "Safeguarding Equipment... To prevent self injury from lack of safety awareness... when in bed... at all times sock to right hand, left arm splint, left arm tucked under sheet... all orders valid for one month."

(i) The Safety Monitoring Sheet, dated 8/3/2020, did not contain documentation of equipment checks every two hours while the patient was in bed on the 11:00 PM - 7:00 AM shift.

(ii) At 11:45 AM, Staff #9 confirmed the patient was in bed from 11:00 PM to 7:00 AM on 8/3/2020.

2. Review of Medical Record #16 on 8/7/20 revealed the following:

a. The Physician's Order Sheet dated 7/23/20 stated, "Safeguarding Equipment... To prevent self injury from lack of safety awareness... when in bed... at all times sock to right hand, left arm splint, left arm tucked under sheet... all orders valid for one month."

(i) The Safety Monitoring Sheet, dated 8/3/2020, did not contain documentation of equipment checks every two hours while the patient was in bed on the 11:00 PM - 7:00 AM shift.

(ii) At 11:50 AM, Staff #9 confirmed that the patient was in bed from 11:00 PM to 7:00 AM on 8/3/2020.

3. Staff #1, Staff #4 and Staff #23 confirmed the above findings.

A. Based on observation, staff interviews, review of facility policy and procedure, and review of personnel files, it was determined that the facility failed to follow infection control standards of practice and failed ensure that its policy and procedure addresses PPE (personal protective equipment) usage for patients positive for COVID-19, is implemented.

Findings include:

Reference: Facility policy, "Infection Control Covid-19 Personal Protective Equipment" states, " ... PPE required for caring for a patient suspected for or diagnosed with Covid-19 is gown, gloves, Respirator face mask and/or face mask, face shield or goggles. PPE must be donned (put on) prior to entering the patient care area/room ... PPE must remain in place and be worn correctly for the duration of work in potentially contaminated areas."

1. During a tour of the Yellow Zone on 8/5/20 at 11:08 AM, the following was observed:

a. Isolation signage for Droplet Precautions was posted outside of Room #331. Upon interview, Staff #3 stated that Patient #7 just returned to the facility from the hospital where he/she had surgery. Patient #7 was under a fourteen (14) day quarantine for COVID-19 as a precautionary measure.

b. Upon interview at 11:10 AM, Staff #3 confirmed that the facility conserves PPE by extending and reusing gowns, N95 face masks, and face shields. He/she stated that gowns worn in isolation rooms, are provided to staff at the beginning of the shift, and hung outside the patient's room for the staff member to use throughout their shift. Staff #3 stated that face shields are labeled with the name of the staff member, stored in Ziploc bags on the isolation cart when not in use, and cleaned with a germicidal wipe after use. Staff #3 stated that N95 face masks are reserved for staff members caring for patients on droplet precautions. He/she stated that N95s are given to staff members at the beginning of their shift to use for the duration of their shift. Staff #3 stated that N95s are stored in a brown paper bag when not in use and are collected in a bin at the end of the staff member's shift.

c. Upon interview at 11:20 AM, Staff #13 identified him/herself as the nurse caring for Patient #7. Staff #13 indicated he/she wears an N95, face shield, gown, and gloves when entering Room #331. When asked where he/she keeps his/her PPE, Staff #13 entered Room #331 and removed a gown and face shield from a hook in the center of the room. Staff #13 stated, "This is mine." Staff #13 confirmed that by storing his/her PPE inside Room #331, he/she must walk into the room without wearing PPE, to retrieve it.

2. During a tour of the Red Zone on 8/5/20 at 11:48 AM, the following was observed:

a. Staff #3 confirmed that Patient #2, in Room #542, was positive for COVID-19. Isolation signage for Droplet Precautions was posted outside of Room #542.

b. A gown and face shield, labeled with the name of a staff member, were observed hanging on a hook outside of Room 542. Upon interview at 11:52 AM, Staff #5 identified him/herself as caring for Patient #2. When asked where his/her PPE was for Room 542, Staff #5 pointed to the PPE hanging on the hook and stated, "I use that one." This surveyor then said, "That PPE is labeled with another person's name - is that the PPE that you use for this room?" Staff #5 then stated that he/she does not use that gown and face shield and that "someone must have thrown mine away."

(i) Staff #5 was asked where he/she kept his/her face shield. Staff #5 went over to an isolation cart in front of Room #532 and stated, "I use this one under here." The face shield identified was not labeled with Staff #5's name. He/she stated, "This was not given to me, but I used it anyway. I cleaned it before I used it. I never got one this morning."

(ii) Staff #5 was observed wearing a surgical mask and was asked where his/her N95 face mask was kept. Staff #5 stated that he/she did not have an N95 face mask. He/she stated, "I did not get one this morning. I wasn't thinking - I know I should have had one. I'm a little frazzled because I'm new and I've been running crazy today." Staff #5 confirmed that he/she was aware that the patient in Room #542 was positive for COVID-19.

(iii) Upon interview, Staff #5 confirmed that nurses have direct access to locked cabinets at the nurse's station containing PPE, including N95 face masks. He/she stated that no other staff member was responsible for dispensing PPE to him/her.

(iv) Staff #5 confirmed that he/she had been in Room #542 twice since the start of his/her shift.

c. Upon interview at 2:20 PM, Staff #3 confirmed that Staff #5 is caring for six (6) other patients, all of whom are negative for COVID-19.

3. Staff #1, Staff #3, and Staff #4 confirmed the above findings.

4. On 8/5/20, Staff #1 was notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to the facility at 4:02 PM. An acceptable IJ removal plan was received from the facility on 8/6/20.

On 8/25/20, an onsite visit was conducted to assess the facility's compliance with the IJ removal plan. During the onsite visit, the following was conducted: A tour of the Green, Yellow, and Red Zones, staff interviews, and a review of staff education and training. The facility was determined to be in compliance with its IJ removal plan and the IJ was removed.

B. Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that its policy and procedure regarding isolation procedures, is implemented.

Findings include:

Reference: Facility policy, "Infection Control Section 3: Prevention" states, " ... Isolation Rooms ... 3. A sign posted on the room entrance door easily identifies the isolation room. ... ."

1. During a tour of the Red Zone on 8/5/20 at 12:05 PM, the following was observed:

a. Upon interview, Staff #3 confirmed that Patient #3 was previously in Room #542 and was moved to Room #563 on 8/4/20.

(i) Upon interview, Staff #3 stated that after Patient #3 was moved to Room #563, he/she was placed on droplet precautions because he/she was previously housed with a patient positive for COVID-19.

b. There was no isolation sign outside of Room #563, indicating that the patient was on droplet precautions.

2. Staff #1, Staff #3, and Staff #4 confirmed the above findings.


Findings include:

C. Based on observation, staff interviews, and review of nationally recognized guidelines, it was determined that the facility failed to adhere to CDC guidance regarding infection control practices used to mitigate the spread of COVID-19.

Findings include:

Reference: Centers for Disease Control and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, updated July 15, 2020 states, "CDC recommends using additional infection prevention and control practices during the COVID-19 pandemic, along with standard practices recommended as a part of routine healthcare delivery to all patients. ... These additional practices include... Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a cloth face covering or facemask for source control and how and when to perform hand hygiene. ... Encourage Physical Distancing... Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission. ... Examples of how physical distancing can be implemented for patients include... Arranging seating in waiting rooms so patients can sit at least 6 feet apart... Designating areas for HCP to take breaks, eat, and drink that allow them to remain at least 6 feet apart from each other, especially when they must be unmasked. ... ."

1. During a tour of the Main Entrance and Main Lobby on 8/5/20 at 11:00 AM, the following was observed:

a. At the Main Entrance to the facility, a sign was posted that encouraged visitors to social distance at least six (6) feet. There were no signs posted that indicated the signs/symptoms of COVID-19 and instructions for those individuals who may be experiencing those signs/symptoms.

b. In the Main Lobby waiting area, chairs were immediately adjacent to each other and not arranged in a way to encourage social distancing. There were no social distancing signs in the Main Lobby waiting area.

2. During a tour of the Staff Dining Room on 8/5/20 at 11:47 AM, the following was observed:

a. There were no social distancing signs present in the Staff Dining Room. Chairs and tables were immediately adjacent to each other and not arranged in a way to encourage social distancing.

b. Two staff members were sitting at a table across from one another. They were in close proximity to each other with their face masks down while they were eating.

3. Staff #1, Staff #3, and Staff #4 confirmed the above findings.

Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure that staff receive education and training on policies and procedures related to COVID-19.

Findings include:

Reference: Facility document, "Infection Control Program" states, " ... Management of Outbreaks: The Infection Control Nurse works collaboratively with the [name of facility] Medical and Educational medical staff, leadership, nursing staff, other staff members, licensed independent practitioners, pertinent family, and community contacts in response to an actual or potential risk/threat of patient influx due to an infectious process that will require care/services over an extended period of time. ... Actions will be taken to contain the spread of the infection and protect the staff, patients, and students exposed to the specific disease. ... Proactive preparation includes ... Staff education for infectious disease specific entities and the use of appropriate personal protective equipment (PPE). ... ."

1. Upon interview on 8/5/20 at 10:30 AM, Staff #3 stated staff members received education on COVID-19 related policies and procedures. He/she stated, "Our nurse managers are constantly going over things with staff. I have also done education with staff."

a. A request was made to Staff #1 and Staff #3 for staff education and training regarding the following COVID-19 related policies and procedures: Screening protocol for employees and visitors, PPE, EVS cleaning protocol, and employee work exclusion and return to work policy. No staff training and education was provided.

b. Upon interview on 8/6/20, Staff #1 and Staff #3 confirmed they were unable to provide evidence of the requested staff education and training for COVID-19 policies and procedures. Staff #1 stated, "We did them. We just didn't document them."

2. Staff #1, Staff #3, and Staff #4 confirmed the above findings.