HospitalInspections.org

Based on review of documentation, interviews and observations, it was determined that the hospital was not in compliance with the Medicare participatory requirements, including failing to operate as a Long-Term Care Hospital (LTCH), as defined in the Social Security ACT, Section §1861.

Findings include:
The Social Security Act, Section §1861(ccc)(1)(3) (4)(a)(b)(c) defines a Long-Term Care Hospital as "is primarily engaged in providing inpatient services, by or under the supervision of a physician, to Medicare beneficiaries whose medically complex conditions require a long hospital stay and programs of care provided by a long-term care hospital; (2) has an average inpatient length of stay (as determined by the Secretary) of greater that 25 days ...... ; (3) satisfies the requirements of subsection (e); and (4) meets the following facility criteria; (A) the institution has a patient review process, documented in the patient medical record, that screens patients prior to admission for appropriateness of admission to a long-term care hospital, validates within 48 hours of admission that patients meet admission criteria for long-term care hospitals, regularly evaluates patients throughout their stay for continuation of care in a long-term care hospital, and assesses the available discharge options when patients no longer meet such continued stay criteria; (B) the institution has active physician involvement with patients during their treatment through an organized medical staff, physician-directed treatment with physician on-site availability on a daily basis to review patient progress, and consulting physicians on call and capable of being at the patient's side within a moderate period of time, as determined by the Secretary; and (C) the institution has interdisciplinary team treatment for patients, requiring interdisciplinary teams of health care professionals, including physicians, to prepare and carry out an individualized treatment plan for each patient."

The Social Security Act, Section §1861(e)(1) defines a hospital as "is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons; ...; (6) ... (B) has in place a discharge planning process that meets the requirements of subsection (ee); (7) in the case of an institution in any State in which State or applicable local law provides for the licensing of hospitals, (A) is licensed pursuant to such law; ... ."

The Social Security Act, Section §1861(ee)(1) states "a discharge planning process of a hospital shall be considered sufficient if it is applicable to services furnished by the hospital to individuals entitled to benefits under this title and if it meets guidelines and standards established by the Secretary under paragraph (2). (2) ... The guidelines and standards shall include the following: (A) The hospital must identify, at an early stage of hospitalization, those patients who are likely to suffer adverse health consequences upon discharge in the absences of adequate discharge planning. (B) Hospitals must provide a discharge planning evaluation for patients identified under subparagraph (A) and for other patients upon the request of the patient, patient's representative, or patient's physician. (C) Any discharge planning evaluation must be made on a timely basis to ensure that appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. (D) A discharge planning evaluation must include an evaluation of a patient's likely need for appropriate post-hospital including ... post-hospital extended care services and the availability of those services, including the availability of home health services through individuals and entities that participate in the program under this title and that serve the area in which the patient resides and that request to be listed by the hospital as available and, in the case of individuals who are likely to need post-hospital extended care services, the availability of such services through facilities that participate in the program under this title and that serve the area in which the patient resides. (E) The discharge planning evaluation must be included in the patient's medical record for use in establishing an appropriate discharge plan and the results of the evaluation must be discussed with the patient (or the patient's representative). (F) Upon the request of a patient's physician, the hospital must arrange for the development and initial implementation of a discharge plan for the patient. (G) Any discharge planning evaluation or discharge plan required under this paragraph must be developed by, or under the supervision of, registered professional nurse, social worker, or other appropriately qualified personnel. ..."

Eleanor Slater Hospital is currently participating in the Medicare program as a Long-Term Care Hospital (LTCH). In order to maintain Medicare certification as an LTCH, the hospital is required to be primarily engaged in providing inpatient services to patients "whose medically complex conditions require a long hospital stay and programs of care provided by a long-term care hospital by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons."

Conversely, in order to participate in the Medicare program as a Psychiatric Hospital, a hospital must be "primarily engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill persons; ... (3) maintains clinical records on all patients and maintains such records as the Secretary finds to be necessary to determine the degree and intensity of the treatment provided to individuals ...; (4) meets staffing requirements as the Secretary finds necessary for the institution to carry out an active program for treatment for individuals who are furnished services in the institution. ... " (The Social Security Act, Section §1861(f)(1)(3)(4)).

On September 13, 2021, at 10:00 AM, the hospital provided a document, "Institutions for Mental Disease (IMD) Medical Necessity Review," dated August 25, 2021, which revealed data that indicated more than half of the patient population had a primary admitting diagnosis related to a psychiatric condition requiring active treatment.

In addition, on September 13, 2021, the hospital provided a "Daily Census Summary" which indicated that the hospital's census consisted of 119 "psychiatric" patients and 84 "medical" patients.

During an interview on September 15, 2021, with EMP-36, at 1:00 PM, EMP-36 indicated that Eleanor Slater Hospital was a "unique type of hospital." EMP-36 indicated that the "Benton" unit, contained patients that are "court-ordered" and are considered "forensic" patients [a patient who the court has either found not guilty by reason of mental illness or detained to a mental illness facility until trial or to serve out a sentence]. EMP-36 further stated that the "Zambarano" unit contained a patient population of patients requiring more "intermediate" level of care, "not acute" level of care or "nursing home" level of care.

During an interview on September 16, 2021, with EMP-35, at 2:00 PM, EMP-35, indicated that the facility was not operating as an LTCH and indicated that the hospital was "unable to take care of LTCH level patients" but does provided custodial care with "some" acute care services being provided to "some" of the patients on the Benton unit.

During an interview on September 16, 2021, with EMP-37, at 2:35 PM, EMP-37 stated that the average length of stay for patients at Eleanor Slater Hospital was "12 years."

Review of correspondence, submitted to CMS on September 16, 2021, by EMP-35, revealed that on April 27, 2021, EMP-35 communicated concerns to EMP-36 regarding the medical necessity of services to the current patients of the hospital. EMP-35 commuted to EMP-36 "our 'hospital' exists to house people with complex social problems not for any medical purposes. We do not and cannot provide LTACH [another acronym used to reflect Long-Term Care Hospital] level of care."

A review of documentation received from the Medicare Administrative Contractor (MAC) revealed that the facility submitted a change of information to reflect a new director, officer and managing employees- which was approved by the MAC on July 16, 2021. In addition, when responding to the question regarding facility type, the hospital's representative selected "other" and documented "State Government Facility" and then clarified that the facility is a "Hospital- Long Term Care PPS [Prospective Payment Systems which is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount.] The MAC indicated that since December 2019, Medicare paid one claim, for reimbursable services, which was in March 2021. In addition, there was no documented evidence that Eleanor Slater Hospital sought assistance or attempted to disenroll from the Medicare program when they identified that they were no longer primarily engaged as a provider of LTCH services in the Medicare program. 42 CFR § 424.516 (e)(1)(2) - Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program, requires a provider or supplier, participating in the Medicare program to " ... (1) Within 30 days for a change of ownership or control, including changes in authorized official(s) or delegated official(s); (2) All other changes to enrollment must be reported within 90 days. ...".

Furthermore, during an interview on September 15, 2021, with EMP-36, at 1:00 PM, EMP-36 indicated that the hospital was certified for 495 Medicare LTCH beds. However, the facility's state operating license, issued by the State of Rhode Island (RI), revealed that the hospital is licensed to operate 230 hospital beds. In accordance with State Law, and as specified in the Social Security Act, Section 1861, the hospital must be operating in accordance with their license. The hospital cannot operate more hospital beds than licensed and allowable by the State.

Eleanor Slater Hospital failed to be primarily engaged as a provider of LTCH services, in accordance with their Medicare certification classification, failed to operate in accordance with their State License and failed to notify the Centers for Medicare and Medicaid Services (CMS) accordingly of changes impacting their Medicare enrollment.

Based on review of the Governing Body By-Laws and employee (EMP) interview, it has been determined that the hospital failed to have a Governing Body that is effective in carrying out its responsibilities for the conduct of the hospital and ensures the hospital is primarily engaged as a provider of long-term care services in accordance with their Medicare certification status as a long-term acute care hospital (LTACH or LTCH).

Findings are as follows:

The Hospital's Governing Body By-Laws, last revised in June 2020, state, in part,

"Section 3.5 Duties and Responsibilities: The Governing Body shall be responsible for the establishment and implementation of policy, for the overall planning and management of the Hospital, for providing and maintaining quality patient care, and for evaluating the Hospital's overall performance ..."

"Section 7.1: The Governing Body of the hospital shall establish a planned, systematic organization-wide approach to performance improvement, analysis, and implementation .... This may be accomplished through the Hospital wide Performance Improvement Steering committee which will be responsible to the Governing Body."

Surveyor review of the Governing Body meeting minutes revealed meetings were held in October 2020, July 2021, and August 2021. The hospital was unable to provide any documentation to indicate, for the months of November 2020 through June 2021, that the Governing Body had met, followed up on any potential action items, evaluated the overall planning, management and quality care for the hospital. These minutes failed to provide evidence that the Governing Body was apprised of patient care services and quality of services provided. The hospital failed to identify current issues which were identified during the survey process as follows:

1. Failure to meet the condition of participation relative to patient rights and patient safety (A-0115, A-0144, A-0130, A-0132, A-0154, A-0175).

2. Failure to assure that hospital's contracted services are reviewed as part of an organization wide quality assurance program (A-0083, A-0263, A-0273, A-0308).

3. Failure to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program that shows measurable improvement in indicators (A-0043, A-0309).

4. Failure to provide nursing care in accordance with accepted standards of nursing practice (A-0395, A-0405).

5. Failure to ensure all patient medical record entries are legible, complete, dated, timed, and authenticated (A-0450).

6. Failure to ensure that the physical plant of the hospital was properly maintained (A-0701).

7. Failure to ensure infection control prevention and surveillance (A-0747, A-0750).

Additionally, the Governing Body failed to establish and maintain a planned, systematic organization-wide approach to performance improvement, analysis, and implementation of policy.

On 9/16/2021 at approximately 2:15 PM, the Chief of Quality Assurance (EMP-10), was unable to provide evidence that the interim Governing Body held meetings during the following months: November 2020, December 2020, January 2021, February 2021, March 2021, April 2021, May 2021, and June 2021.

During an interview with the Chief of Quality Assurance, EMP-10 and the Administrator of Accreditation, EMP-1, on 9/14/2021 at approximately 2:20 PM, they acknowledged that the hospital failed to maintain an effective, ongoing, hospital-wide quality assessment and performance improvement program that shows measurable improvement in indicators that will improve health outcomes as evidenced by the hospitals failure to identify and address the issues identified above.

During an interview with the interim Chief Executive Officer (CEO) at 1PM on 9/15/2021, The CEO said he/she was nominated for his/her position as interim CEO of Eleanor Slater Hospital (ESH) by the Governor which was then confirmed by the Senate. The CEO said he/she, alone, comprised the hospital's Governing Body Committee. The CEO described the hospital as a "unique type of hospital" further stating the Benton location consisted of a patient population that were all "court ordered" forensics patients and the Zambarano Location consisted of a patient population that, he/she described, as being more "intermediate" level of care, "not acute" level of care and not "nursing home" level of care. The CEO said it was his/her understanding the hospital was certified by the Center's for Medicare and Medicaid Services (CMS) as a 495 bed LTACH.

The ESH's Rhode Island State Licensure Certification (hung in the lobby entrance of the Regan Building), dated as issues 10/17/1994 with expiration of 12/31/2021, indicated the hospital was licensed for 230 hospital beds.

In a CMS publication titled: What are Long-Term Care Hospitals, dated June 2019, (https://www.medicare.gov/Pubs/pdf/11347-Long-Term-Care-Hospitals.pdf) CMS defines LTCH's as: "Most people who need inpatient hospital services are admitted to an "acute care" hospital for a relatively short stay. But some people may need a longer hospital stay. Long-term care hospitals (LTCHs) are certified as acute care hospitals, but LTCHs focus on patients who, on average, stay more than 25 days. Many of the patients in LTCHs are transferred there from an intensive or critical care unit. LTCHs specialize in treating patients who may have more than one serious condition, but who may improve with time and care, and return home. LTCHs generally give services like respiratory therapy, head trauma treatment, and pain management." "Do LTCHs provide long-term care? No. Long-term care usually refers to care that's basically custodial, like help with feeding or dressing, even if there's some health care given. Medicare doesn't cover this kind of care, which can be given in your own home or in facilities, like assisted living facilities. LTCHs are hospitals that give inpatient services to people who need a much longer stay to get well."

The Director of Nursing Services (DNS), in the presence of the survey team and EMP-10, was interviewed at 2:35 PM on 9/16/2021. The DNS said the hospital's average length of stay for the patients at ESH was 12 years.

The CMS Medicare Benefit Policy Manual Chapter 2 - Inpatient Psychiatric Hospital Services, rev. 253, dated 12/14/18, defines an Inpatient Psychiatric Hospital as: "an institution that is primarily engaged in providing, by or under the supervision of a physician, psychiatric services for the diagnosis and treatment of mentally ill patients, maintains clinical records necessary to determine the degree and intensity of the treatment provided to the mentally ill patient, and meets staffing requirements sufficient to carry out active programs of treatment for individuals who are furnished care in the institution."

The Medicaid and CHIP Payment and Access Commission (MACPAC) defines an Institutions for Mental Diseases (IMD) as a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, which includes substance use disorders (SUDs).

In the Glossary of CMS.gov, CMS defines an inpatient hospital as a facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical) and rehabilitation services by or under the supervision of physicians, to patients admitted for a variety of medical conditions

In the Glossary of CMS.gov, CMS defines a psychiatric facility as a facility for the diagnosis and treatment of mental illness on a 24-hour basis, by or under the supervision of a physician.

In the Glossary of CMS.gov, CMS defines a Skilled Nursing Facility (SNF) as a facility (which meets specific regulatory certification requirements) which primarily provides inpatient skilled nursing care and related services to patients who require medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.

On 9/13/2021, at approximately 10AM, the hospital provided a medical necessity review report, titled: Institutions for Mental Disease (IMD) Medical Necessity Review, dated 8/25/2021, conducted by Butler Hospital. The report indicated, as of May 2021, the Eleanor Slater Hospital revealed more than half of the patient population had a primary diagnosis of a psychiatric illness.

On 9/13/2021, the Surveyor asked EMP-10 for a current list of all patients with their primary diagnosis, payer source and a floor plan with the designated provision of care for each unit.

On 9/13/2021, EMP-10 provided the survey team with a document/list of all patients with their admitting diagnosis for all units (also referred to, by the hospital, as wards). This document was titled: "Diagnoses for Patients on Ward", date 9/13/2021.

On 9/16/2021, EMP-10 provided the survey team with a floor plan for each unit of the hospital with the current designation (level) of care being provided on each unit. The floor plans indicated, as of 9/16/2021, the hospital's designation of their patient's level of care based on their primary diagnoses as the following:
Regan Building, 4th floor: 25 patients: 5 medical patients, 20 psychiatric patients
Regan Building, 5th floor: 12 patients: 9 medical patients, 3 psychiatric patients
Adolf Meyer Building, 1st floor: 11 patients: 2 Developmental Disability (DD), 1 Forensic, 8 Psychiatric
Adolf Meyer Building, 2nd floor: 11 patients: 4 Forensic with DD, 1 DD, 6 Psychiatric
Adolf Meyer Building, 3rd floor: 20 patients: 11 Forensic with DD, 9 Psychiatric
Benton Building: 51 patients: all 51 Forensic

Although the hospital labeled, on the floor plans, each unit of the Zambarano Building as LTACH (long term acute care hospital) level of care, the hospital's document: "Diagnoses for Patients on Ward", dated 9/13/21, indicated the following admitting diagnoses:
Zambarano Building: 68 patients: 12 Dementia, 2 psychiatric, 24 quadriplegia/ hemiplegia/paraplegia, 2 morbid obesity, 4 vegetative state, 24 (other).

The Surveyor toured the Zambarano location at 11:25 AM on 9/14/2021 with EMP-32 and EMP-34. EMP-32 and EMP-34 said the following during the observational tour:
the Zambarano building had four open units: South One, South Two, North One and North Three. South One was a "secured unit" (locked unit) for patients who wander, diagnoses of dementia and some patients with traumatic brain injuries (TBI) (there were a total of 10 patients on the unit). South Two was an "open mixed unit" with mostly "bed bound" patients. They said the unit was not a unit for new admissions and diagnoses included quadriplegia, paraplegia, TBI and DD. North Two was described as a "mixed unit" with diagnoses that included TBI, DD, quad/paraplegia, and respiratory. The unit had two patients with tracheostomies, no patients on ventilators. North Three was described as a mixed unit with diagnoses that included DD, brain injury, respiratory and patients who wander. The unit had 5 patients with tracheostomies, no patients on ventilators.

During an interview on 9/16/21 at 2:00 PM, with the Acting Chief Medical Officer (ACMO ((EMP-35)) who stated the facility was not a Long-Term Care Hospital (LTCH) , explaining that ventilator weaning and wound care accounted for less than 10% of patient load as a reason the LTCH designation is incorrect. EMP-35 stated the facility is "unable to take care of LTCH level patients and provides custodial care with some acute care provided on the forensic (Benton) unit."



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Based on record review and employee (EMP) interview it has been determined that the hospital failed to meet the Condition of Participation of Patient's Rights relative to care in a safe setting related to 1 of 1 patient retaliation by staff, Patient ID# 6, and observation/safety checks for 17 of 33 sample patients, Patient ID#'s 15, 16, 17, 18, 22, 32, 33, 35, 36, 37, 38, 39, 40, 41, 42, 43, and 44).

Findings are as follows:

1. The hospital failed to ensure that patients' rights are protected, (Patient ID #18). Refer to A-0130

2. The hospital failed to correctly transcribe a patients advanced directive on the "Resuscitative/End of Life Care Form, (Patient ID #15). Refer to A-0132

3. The hospital failed to complete the required observation/safety checks for 17 patients, (Patient ID#'s 15, 16, 17, 18, 22, 32, 33, 35, 36, 37, 38, 39, 40, 41, 42, 43, and 44). Refer to A-0175, A-0144

4. The hospital failed to provide the necessary supervision to maintain safety, (Patient ID #18). Refer to A-0175

5. The hospital failed to prevent the inappropriate use of a restraint imposed as a means of retaliation by staff, (Patient ID #6). Refer to A-0154

6. The hospital failed to monitor patients placed in restraint devices to ensure their physical and psychological needs were met, (Patient ID#'s 18 and 22). Refer to A-0175

Based on record review and employee (EMP) interview, it has been determined that the hospital has failed to meet the Condition of Participation (COP) for Quality Assessment and Performance Improvement (QAPI) as evidenced by the hospital's failure to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program that shows measurable improvement in indicators that will improve health outcomes as evidenced by the hospitals failure to address the following issues:

1. Failure to meet the condition of participation relative to patient rights and patient safety (A-0115, A-0144, A-0130, A-0132, A-0154, A-0175).

2. Failure to assure that hospital's contracted services are reviewed as part of an organization wide quality assurance program (A-0083, A-0263, A-0273, A-0308).

3. Failure to develop, implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program that shows measurable improvement in indicators
(A-0043, A-0309).

4. Failure to provide nursing care in accordance with accepted standards of nursing practice
(A-0395, A-0405).

5. Failure to ensure all patient medical record entries are legible, complete, dated, timed, and authenticated (A-0450).

6. Failure to ensure that the physical plant of the hospital was properly maintained (A-0701).

7. Failure to ensure infection control prevention and surveillance (A-0747, A-0750).

During an interview with the Chief of Quality Assurance, EMP-10 and the Administrator of Accreditation, EMP-1, on 9/14/2021 at approximately 2:20 PM, they acknowledged that the hospital failed to maintain an effective, ongoing, hospital-wide quality assessment and performance improvement program that shows measurable improvement in indicators that will improve health outcomes as evidenced by the hospitals failure to identify and address the issues identified above.

Based on record review, employee (EMP) interview, and observations, the hospital failed to ensure that the physical plant of the hospital was properly maintained (A0701) and based on a Life Safety Code survey performed during a CMS authorized Recertification survey completed on September 15, 2021, at Eleanor Slater Hospital, the Condition for Physical Environment is not met.

See Form CMS-2567(s) Life Safety Code reports for additional cited deficiencies.

Based on record review, observation and employee (EMP) interview, the hospital failed to have an effective hospital-wide program for the surveillance and prevention of the SARS-CoV-2, 2019 Novel Coronavirus on all campuses.

Findings are as follows:

The hospital failed to demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for the prevention of transmission of the SARS-CoV-2, 2019 Novel Coronavirus as evidenced by failure to complete COVID-19 screening protocols upon entry to 2 of 4 hospital buildings.

Additionally, the hospital failed to implement infection control measures to provide a sanitary environment and prevent the transmission of communicable diseases and infections relative to wound care for 1 of 3 sample patient with wounds, observed donning personal protective equipment (PPE), EMP-3. (Refer to A-750).

Based on record review and employee (EMP) interview the hospital's governing body failed to assure that hospital's contracted services are provided in compliance with the Medicare Conditions of participation and reviewed as part of an organization wide Quality Assurance and Performance Improvement program.

Surveyor review of the Quality Assurance and Performance Improvement (QAPI) meeting minutes revealed the QAPI Committee did not meet during the following months: September 2020, October 2020, November 2020, December 2020, January 2021, February 2021, March 2021, and April 2021.

During an interview with the Chief of Quality Assurance (EMP-10) and the Administrator of Accreditation, (EMP-1) on 9/14/2021 at approximately 2:20 PM, they were unable to provide documented evidence that the Contracted Services which consists of optometry, cardiology, neurology, podiatry, dental, ophthalmology, and urology, were being monitored to ensure compliance and quality. Additionally, they acknowledged that the Contracted Services are not integrated into the hospitals QAPI program.

Based on employee (EMP) interview and record review it has been determined the hospital failed to ensure the patient has the right to receive a meal provided by family and identified in accordance with the patients care plan and medically ordered diet for 1 of 5 sample patients, Patient ID #18.

Findings are as follows:

Review of Patient ID #18's record revealed she/he was admitted to the hospital in April of 2016 and has a current diagnosis of Pervasive Developmental Disorder (refers to a group of disorders characterized by delays in the development of socialization and communication skills, including Autism) and Insulin Dependent Diabetes Mellitus.

Review of Patient ID# 18's Care Plan last updated on 9/9/2021 reveals a nursing diagnosis of "Ineffective therapeutic regimen management related to knowledge deficit as evidence by inability to understand the importance of medically ordered diet" with an intervention provided to, "...Reinforce with patient and family that when meals are brought in from outside of the hospital, patient will have a choice between either the family provided meal or medically ordered meal, but not both..."

Review of a nurse's notes dated 9/4/2021, authored by registered nurse (RN), EMP-15, revealed the patient had refused his/her hospital provided supper meal that evening, and called his/her family to bring an alternate meal.

Record review indicated the family had been educated on foods that the patient could have based on his/her diet orders. Observation of an approved list of foods posted at the nursing station for Patient #18 confirmed the food (a sandwich) the patient's family brought in that evening (9/4/2021) was in compliance with his/her therapeutic diet orders.

Record review reveals EMP-15 did not allow the patient to have the meal (sandwich) brought in by family, failing to allow the patient a choice between the family provided meal or the hospital provided meal as stated in the patient's care plan.

During an interview with the Nurse Manager, EMP-13, on 9/14/2021 at approximately 10:00 AM, she/he was unable to provide evidence that the hospital provided treatment in accordance with the patient's care plan.

Based on record review and employee (EMP) interview, it has been determined that the hospital incorrectly transcribed a patients advanced directive on his/her "Resuscitative/End of Life Care Form" resulting in 1 of 5 sample patients, Patient ID #15, having his/her advanced directive incorrectly documented on the "Resuscitative/End of Life Form."

Findings are as follows:

Surveyor review of Patient ID #15's medical record revealed that s/he has a past medical history of a brainstem cerebrovascular accident (CVA) which has resulted in him/her being unable to move, except for eye movement.

Further review of the medical record revealed a Patient Care Plan dated 8/12/2021 and a Provider Order from 9/7/2021 both identifying Patient ID #15's Code Status as Do Not Resuscitate.

The "Resuscitative/End of Life Care Form," which was completed and signed by the provider, EMP-5, on 9/10/2021 at 1:15 PM, identified Patient ID #15 as wanting to have cardiopulmonary Resuscitation (CPR) performed along with "full treatment" (all interventions necessary to sustain life).

During an interview with the Nurse Coordinator, EMP-2, on 9/17/2021 at approximately 11:25 AM, she/he stated that the "Resuscitative/End of Life Form" is used by nursing to identify the patient's code status.

During an interview with EMP-5 on 9/17/2021 at approximately 11:30 AM, she acknowledged that she/he failed to correctly identify Patient ID #15's code status on the "Resuscitative/End of Life Form."

Based on record review, and employee (EMP) interview, the hospital failed to provide a safe environment for 15 of 15 patients on the Reagan unit that were on safety checks (Patient ID#'s 15, 16, 17, 32, 33, 35, 36, 37, 38, 39, 40, 41, 42, 43, and 44).

Findings are as Follows:

1. Review of the hospitals "Patient Observation" policy, which was last approved on 2/24/2020, reveals:
" ...Definitions ...

5 Minute [and] 15 Minute [safety checks]: Requires an assigned staff member to visually observe and document the patient safety status at the ordered interval. Staff member will be assigned to monitor and observe the patient every five minutes. Staff will document on the Q [every] 5-minute check observation form ...

Procedures ...
c. The RN [Registered Nurse] will communicate the level of observation during shift report.
d. The RN will review the level of observation with all nursing staff during each shift report ...
h. The staff will document patient observations on the appropriate forms."

Review of the unit "Checks Assignment Sheet" revealed that for 9/13/2021 there were 15 patients on the unit requiring observation.
2 required every 15-minutes, Patient ID#'s 35 and 36.
3 required every 30-minutes, Patient ID's 17, 32, and 39.
10 required hourly, Patient ID#'s 15, 16, 33, 37, 38, 40, 41, 42, 43, and 44.

Review of the patient safety check assignment sheet on 9/13/2021 at approximately 2:30 PM revealed there were no entries on the safety check sheet for 15 of 15 patients on the Reagan Unit from 1:45 PM until 2:30 PM. However, at 2:45 PM, a second review of the assignment sheet revealed that EMP-30 went back and documented the safety checks as completed.

During an interview with EMP-2 on 9/13/2021 at 2:35 PM, she/he acknowledged that there was no evidence that the safety checks were performed.

During an interview with EMP-30, who was responsible for completing the safety checks, she/he stated that she/he did not perform the safety checks at 2:00 PM, 2:15 PM or 2:30 PM and admitted to signing off the safety checks as being performed when she/he had not visually observed the patients.

Review of the unit "Check Assignment Sheet" from 9/14/2021 at approximately 12:15 PM revealed there was no evidence of safety checks being performed on the Reagan unit from 10:45 AM until 12:15 PM, as the check boxes were blank.

During an interview with EMP-2 on 9/14/2021 at 12:15 PM, she/he acknowledged that EMP-30 had not completed the safety checks as required and revealed no other staff member had been assigned to do the safety checks while EMP-30 was on break.

Based on record review, observation of the hospital security video, and employee (EMP) interview, the hospital failed to prevent the inappropriate use of restraint imposed as a means of retaliation by one employee, EMP-22, for 1 of 10 patients reviewed for restraints.

Findings are as follows:

Patient ID #6 was admitted in July 2021 with a diagnosis of Schizoaffective Disorder, Bipolar Type. The patient experiences symptoms of hallucinations, delusions, and behavioral outbursts.

Review of an incident report dated 9/2/2021 reveals Patient ID #6 experienced a medical episode evidenced by seizure like activity during a restraint which was initiated by EMP-22, resulting in transfer to an acute care hospital Emergency Department.

Review of a hospital surveillance video of the restraint performed on 9/2/2021, identifies Patient ID #6, throwing a cup of water at EMP-22. In response to this incident, EMP-22 was noted to turn toward and lunge at the patient who was running away from the employee. EMP-22 then chased Patient ID #6, grabbed him/her from behind and swung the patient's body to the floor in an attempt to physically restrain the patient.

During an interview on 9/14/2021 at approximately 9:00 AM, with the Director of Security, EMP-19, who was present during surveyor review of the video, he/she acknowledged this was not an approved restraint as the patient was restrained while trying to flee from EMP-22.

Based on record review, staff interview and observation of the hospital video surveillance, the hospital failed to implement restraint techniques appropriately and safely for 1 of 10 patients reviewed for restraints, (Patient ID #6).

Findings are as follows:

Patient ID #6 was admitted in July 2021 with a diagnosis of Schizoaffective Disorder, Bipolar Type. The patient experiences symptoms of hallucinations, delusions, and behavioral outbursts.

Review of an incident report dated 9/2/2021 reveals Patient ID #6 experienced a medical episode evidenced by seizure like activity during a restraint which was initiated by EMP-22, resulting in transfer to an acute care hospital Emergency Department.

Review of a hospital surveillance video of the restraint performed on 9/2/2021, identifies Patient ID #6, throwing a cup of water at EMP-22. In response to this incident, EMP-22 was noted to turn toward and lunge at the patient who was running away from the employee. EMP-22 then chased Patient ID #6, grabbed him/her from behind and swung the patient's body to the floor in attempt to physically restrain the patient. Upon being brought down to the floor the patient experienced a medical episode evidenced by body tremors and thrashing resulting transfer to a medical unit for observation.

During an interview on 9/14/2021 at approximately 9:00 AM, with the Director of Security, EMP-19, who was present during surveyor review of the video, he/she acknowledged this was not an approved restraint as the patient was restrained while trying to flee from EMP-22.

Based on record review, employee (EMP) interview and review of hospital policy, it has been determined that the hospital failed to adhere to their own policy relative to nursing assessments and continuous observation for 2 of 10 patients reviewed for use of restraints, Patient ID#'s 18 and 22.

Findings are as follows:

Review of the hospital's document entitled, "ELEANOR SLATER HOSPITAL RESTRAINT POLICY AND PROCEDURE ", last revised in June 2021, states in part:

"...B. ASSESSMENT & MONITORING OF A PATIENT IN RESTRAINT

All patients in restraint devices shall be monitored to ensure their physical and psychological needs are met and that their dignity, privacy, and well-being are preserved. This includes the following at minimum:

Continuous observation with 5-minute documentation by any of the following persons ...Certified Nursing Assistant (CNA), Institution Attendant- Psychiatric (IAP), Psychiatric Technician (Psych Tech) and Mental Health Worker (MHW).

A Registered Nurse (RN) shall perform the first 5-minute check and then do an assessment every 15 minutes to determine the individual needs of the patient and communicate to the skilled nursing staff. The assessment is documented on the restraint observation sheet every 15 minutes...

C.RESTRAINT APPLICATION. ASSESSMENT AND RELEASE

5. The RN will perform an assessment immediately upon application of the restraint and every 15 minutes until restraint completion. The assessment(s) will be documented on the Restraint Observation Form..."

1. Review of Patient ID# 18's medical record revealed s/he was admitted to the hospital in April of 2016 and has a current diagnosis of Pervasive Developmental Disorder (refers to a group of disorders characterized by delays in the development of socialization and communication skills, including Autism).

Surveyor review of Patient ID# 18's "Restraint Observation Form[s]" from 8/11/2021 through 9/12/2021 reveals the following:

8/13/2021- The patient was placed in restraints at 7:00 PM, without an indication of a release time. The form lacks evidence that an RN made any assessments of the patient after 7:25 PM.

9/12/2021- The patient was restrained from 5:00 PM until 6:00 PM. This form lacks evidence that an RN assessed the patient every 15 minutes.

2. Surveyor review of Patient ID# 22's medical record revealed she/he was admitted to the hospital in September of 2013 and has a current diagnosis of Borderline Personality Disorder.

Surveyor review of Patient ID# 22's "Restraint Observation Form[s]" from 8/31/2021 through 9/13/2021 revealed the following:

8/31/2021- The patient was restrained from 9:25 AM until 1:25 PM. The forms lack evidence that the patient was assessed every 15 minutes by an RN.

9/10/2021- The patient was placed in restraints at 12:15 AM until 1:00 AM. This form lacks evidence that the patient was assessed every 15 minutes by an RN, or that she/he was assessed every 5-minutes by a CNA, IAP, Psych Tech or MHW.

9/12/2021 & 9/13/2021- The patient was restrained from 9/12/2021 at 11:00 PM until 9/13/2021 at 4:00 AM. The forms lack evidence that the patient was assessed every 15 minutes by an RN.

During an interview with the Nursing Manager, EMP-13, on 9/17/2021 at approximately 10:00 AM, he/she was unable to provide evidence that the hospital policy had been followed relative to nursing restraint monitoring and documentation for the above patients.

Based on record review, employee (EMP) interview and review of hospital policy, it has been determined that the hospital failed to provide a patient, a face-to-face assessment in person within 1-hour after the initiation of a restraint for 2 of 10 patients reviewed for use of restraints, Patient ID#'s 18 and 22.

Findings are as follows:

Review of the hospital's document entitled, "ELEANOR SLATER HOSPITAL RESTRAINT POLICY AND PROCEDURE ", last revised in June 2021, states in part:

"...B. ASSESSMENT & MONITORING OF A PATIENT IN RESTRAINT

A face-to-face patient assessment/evaluation by a Supervising Registered Nurse (SRN) or LIP [licensed independent practitioner] shall be done within the first hour of the restraint...

1. Review of Patient ID# 18's medical record revealed she/he was admitted to the hospital in April of 2016 and has a current diagnosis of Pervasive Developmental Disorder (refers to a group of disorders characterized by delays in the development of socialization and communication skills, including Autism).

Surveyor review of Patient ID# 18's "Restraint Observation Form[s]" from 8/11/2021 through 9/12/2021 reveals the following:

8/11/2021- The patient was restrained from 9:45 AM until 11:45 AM. The form lacks evidence that an RN made any assessments of the patient during this restraint, or that the she/he was assessed by any staff after 10:30 AM.

8/16/2021- The patient was placed in restraints from 7:00 AM until 8:15 AM. The patient did not receive a face-to-face assessment/evaluation by an SRN or LIP until 12:00 PM (3 hours and 45 minutes after being released from the restraint).

During an interview with the Nursing Manager, EMP-13, on 9/17/2021 at approximately 10:00 AM, she/he was unable to provide evidence that the hospital policy had been followed relative to nursing restraint monitoring/assessments.

Based on record review, observation and interview, the hospital failed to ensure lesser restrictive measures were attempted and documented for one (PT ID #28) out of 10 patients reviewed for restraints.

Findings are as follows:

Record Review indicated Patient ID #28 was admitted to the acute care hospital in 2015 with a primary admission diagnoses of Muscular Dystrophy and functional quadriplegia.

During tour of the Zambarano Building at 11:25 AM on 9/14/2021 with EMP-32 and EMP-33, Patient ID #28 was observed sitting in his/her room in a reclining wheelchair. In the room was a large opaque box approximately 4.5 feet tall by 5 feet wide with a mattress on the floor inside the box identified by EMP-32 and EMP-33 as a "Craig's Bed". EMP-32 and EMP-33 said (PT ID #28) used the "Craig's Bed" to sleep in and was not able to get out of it when s/he was in it. EMP-32 and EMP-33 said they did not consider this to be a restraint.

A Physician's Note, dated 3/14/2016, indicated PT #28 had never spoke, walked or attended school. The Note indicated PT ID #28 grew up on floor mats and moves using their hands and elbows.

A Plan of Care dated 9/8/2021 indicated PT ID #28 was a high fall risk and to: maintain Craig's bed for safety.

During interview at 11:08 AM on 9/17/2021 EMP-31 said s/he had worked on the Zambarano Unit for 11 years. EMP-31 said PT ID #28 had been there for many years and had always slept in the "Craig's Bed" for naps during the day and in the evening. EMP-31 said the "Craig's Bed" limited PT ID #28's mobility to within the confines of the "Craig's Bed."

Review of Patient #28's record provided no documentation to indicate any other interventions or strategies to promote safety in a less restrictive environment had been attempted.

Based on review of the Quality Assessment and Performance Improvement (QAPI) Committee meeting minutes and dashboard, and employee (EMP) interview, it has been determined that the hospital's governing body failed to ensure that the QAPI program was being maintained and included all hospital services and departments.

Findings are as follows:

Review of the hospital's Performance Improvement Plan for 2021-2022 revealed the following:

" ...Program Objective...the use of data to assist with the delivery of high-quality healthcare, ongoing monitoring and evaluation of important aspects of care and service, and continuous improvement of systems and processes" is one of the key components of the QAPI process to meet the hospitals organizational goals and carry out its vision. The plan further states that the committee meets monthly and represents all services in the hospital.

Surveyor review of the QAPI meeting minutes revealed the QAPI Committee did not meet from September 2020-April 2021. There was no documentation of QAPI meeting minutes during this timeframe to indicate the hospital was evaluating and ensuring the maintenance of an effective, hospital-wide QAPI program.

During an interview with the Chief of Quality Assurance, EMP-10, and the Administrator of Accreditation, EMP-1, on 9/14/2021 at approximately 2:20 PM, they were unable to provide evidence that the QAPI data collection dashboard indicators were collected and reviewed from September 2020 to March 2021. Additionally, the Chief of Quality Assurance, EMP-10, acknowledged that Contracted Services, which consisted of optometry, cardiology, neurology, podiatry, dental, ophthalmology, and urology were not integrated into the hospitals QAPI program.

Based on record review and employee (EMP) interview it has been determined that the hospital's Governing Body and medical staff failed to ensure the ongoing program for quality improvement and patient safety is defined, implemented, and maintained. That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained. That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated and that the determination of the number of distinct improvement projects is conducted annually.

Findings are as follows:

Review of the hospital's Performance Improvement Plan for 2021-2022 revealed that "The Governing Body of [the hospital] bears ultimate responsibility for setting policy, financial, strategic direction, and the quality of care and services provided by all practitioners and non-clinical staff. Together with the organization's management and medical staff leaders, the Governing Body sets priorities for performance improvement activities..."

During an interview with the Chief of Quality Assurance, EMP-10 on 9/14/2021 at approximately 2:20 PM, she/he acknowledged that the Governing Body meeting minutes were sparce, with minutes only for October 2020, July 2021, and August 2021, and these minutes failed to identify actions which were discussed at those Governing Body meetings, or at any other time from October 2020 to July 2021.

During an interview with the hospital's interim CEO, EMP-36, at 1PM on 9/15/2021, and several times throughout the survey. EMP-36 said she/he was hired in July of 2021 and could not provide evidence of hospital-wide quality assessment and performance improvement efforts addressing priorities for improved quality of care and patient safety and if improvement actions were being evaluated.

Based on observation, record review, and employee (EMP) interview, it has been determined that the hospital failed to provide nursing care in accordance with accepted standards of nursing practice relative to following physician's orders for 2 of 33 patients, (Patient ID #'s 6 and 9).

Findings are as follows:

1. Patient ID #6 was admitted in January 2020, with a diagnosis which includes schizophrenia, traumatic brain injury and attention deficit disorder.

Patient ID #6 had fluxuations noted in his/her weight since admission in 2020.

Record Review for Patient ID #6 reveals a physician's order dated 8/31/2021 for a dietary consult.

Further review of Patient ID #6's medical record revealed no documentation that a dietary consult had been completed.

During an interview with the Clinical Nurse Manager, EMP-13, on 9/14/2021 at approximately 12:00 PM, she/he was unable to provide evidence that Patient ID #6 had a dietary consult according to the physician's order.


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2. Record review for Patient ID #9, reveals s/he was admitted to the hospital in 2014 with a diagnosis of anoxic brain injury, dementia with behavioral disorder, and insulin dependent diabetes.

Review of the Physicians Orders on 9/14/2021 for Patient ID #9 reveals a current order for
Lab work including a TSH (thyroid stimulating hormone) and Vitamin D to be completed every 6 months.

Review of the record reveals the last TSH and Vitamin D lab results for Patient ID #9 were received 2/23/2021. There were no lab results for the month of August 2021 which is when the next specimen would have been due.

During an interview with the staff nurse, EMP-18 on 9/14/2021 at approximately 11:30 AM, when asked where the labs were that were due in August, she/he informed the surveyor that the orders for lab tests are kept on an index card at the nurse's desk. Review of the card reveals that the next TSH & Vitamin D were listed as being due in November.

Based on record review, employee (EMP) interview, and policy review it has been determined that the hospital failed to administer medications in accordance with their policy and/or per the orders of the provider for 2 of 33 sample patients, Patient ID #'s 1 and 18.

Findings are as follows:

1. Patient ID# 1 was admitted in April 2021 with a diagnosis which includes schizoaffective disorder-bipolar type (hallucinations or delusions, and mood disorder symptoms).

Review of the Patient ID #1's medication administration record (MAR) dated September 2021, revealed that the patient did not receive their ordered 2:00 PM doses of the following medications:
-Seroquel 150 mg (antipsychotic, treats mania associated with bipolar disorder)
-Gabapentin 800 mg (used to treat neuropathic pain)
-Clonidine 0.1 mg (treats attention deficit hyperactivity disorder and hypertension)

During an interview on 9/14/2021 with the Clinical Nurse Manager EMP-13, she/he confirmed that there is no documented evidence that the patient received their 2:00 PM medications as ordered by the physician.


2. Review of the hospital's policy entitled "ELEANOR SLATER HOSPITAL DEPARTMENT OF NURSING MEDICATION MANAGEMENT", last revised in 7/2020, states, in part,
"...III. SPECIAL MEDICATIONS
B. INSULIN...
PURPOSE: To ensure accuracy in transcribing, administering, and documenting the use of insulin.

1. An independent double check is required for all insulin orders: this means that the second independent check by a second nurse must confirm the medication order on the Medication Administration Record (MAR). The second nurse completing the double check will observe that the insulin dose is prepared using the correct vial and that the dose drawn is in the correct amount..."

Surveyor review of Patient ID# 18's August 2021 and September 2021 MARs revealed she/he has an order dated 8/2/2021 for Lantus Insulin 36 units subcutaneously at 8 PM daily.

Further review of these MARs fails to reveal evidence that an independent double check of the insulin administration for this order was conducted by another nurse from 8/2/2021 through 9/9/2021.

During an interview with the Nurse Manager, EMP-13, on 9/14/2021 at approximately 9:20 AM, she/he acknowledged nursing staff failed to follow the hospital's policy for the administration of insulin.

Based on record review and employee (EMP) interview it has been determined that the hospital failed to ensure all patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures for 4 of 26 sample patient records, Patient ID#s 16,18, 22 and 23.

Findings are as follows:

1. Surveyor review of the medical record for Patient ID# 18 revealed a document entitled "COLUMBIA-SUICIDE SEVERITY RATING SCALE", a tool used to rate the suicide risk of a patient, this document was only partially completed, not dated or timed.

2. Surveyor review of Patient ID #22 revealed nursing notes for 7AM- 3PM shifts dated 9/10/2021, 9/14/2021 and 9/15/2021 that were not timed. Additionally, there is a nurse note that was neither dated nor timed.

During an interview with the Supervising Registered Nurse, EMP-14, on 9/16/2021 at approximately 9:00 AM, she/he was unable to explain why staff had not timed or dated documents in the above-mentioned patient records per regulatory requirements.

3. Surveyor review of the medical record for Patient ID# 16 revealed an illegible Provider Progress Note dated 9/7/2021 at 4:30 PM. The surveyor interviewed EMP-20, a unit Registered Nurse (RN), on 9/16/2021 at 10:30 AM regarding the legibility of this note. When asked to read the note, EMP-20 stated that it was "challenging" to decipher the note and acknowledged there were several words she/he was unable to read.

4. Surveyor review of the medical record for Patient ID# 23 revealed an illegible Physical Therapy Progress Note from 8/16/2021 at 1:20 PM. The surveyor interviewed EMP-4, the Unit Ward Clerk, about the legibility of this note on 9/17/2021 at 12:02 PM. EMP-4 stated that she/he was unable to read the handwritten note and that she/he could not identify who wrote this note, as it was illegible.

During an interview with the Nurse Manager, EMP-13, on 9/17/2021 at approximately 1:20 PM she/he acknowledged all documentation should be legible, dated and timed when written.

Based on surveyor observation and employee (EMP) interview, it has been determined that the hospital failed to ensure all medications are secured and locked on 1 of 2 nursing units in the Regan building for 5 of 7 sample lock boxes (locked cabinets in patient rooms for medication storage). Additionally, the hospital failed to ensure that all the lock boxes are secured and locked.

Findings are as follows:

During an observation on the Regan 5 unit on 9/15/2021 between approximately 2:00 PM- 2:30 PM, the surveyor observed various medications including eye ointments, nasal spray, and rash ointment on top of the lock boxes, located in patients rooms, instead of secured and locked inside the box.

During an interview on 9/15/2021, during the observations, with the Administrator of Accreditation Standards, EMP-1 who observed the medications on top of the lock boxes with the surveyor. She/he acknowledged that the medications should have been stored inside the boxes and the boxes should have been locked.

Based on record review, employee (EMP) interview, and observations, the hospital failed to ensure that the physical plant was properly maintained (A0701). A Life Safety Code survey performed during a CMS authorized Recertification survey completed on September 17, 2021, at Eleanor Slater Hospital, identified the Condition for Physical Environment is not met. See Form CMS-2567(s) Life Safety Code reports for additional cited deficiencies.

Findings are as follows:

1. A tour of the Eleanor Slater Hospital-Zambarano Hospital building was conducted on 9/14/2021 with the Administrator of Safety and Security, the Associate Director of Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH), and the Acting State Buildings and Grounds Officer. The following environmental issues were revealed:

-The interior walls of the elevator passenger car were found to be broken, peeling and in overall poor condition
-The center stairwell walls, rooms South (S) 1-1, S 1-12, S 2-4, and the second-floor hallway walls had excessive areas of peeling paint
-The hallway by the staff breakroom, rooms S 1-1, S 1-10, and North (N) 2-25 had damaged baseboard molding.
-The shower room S 2-5 had black matter in the grouting of the shower walls
-Room S 1-12 had broken floor tiles

2. A tour of the Eleanor Slater Hospital-Adolph Meyer (AM) building was conducted on 9/15/2021 with the Administrator of Safety and Security, the Associate Director of BHDDH, and the Chief Property Manager-Special Projects Division of Capital Asset Management & Maintenance (DCAMM). The following environmental issues were revealed:

-Unit AM-7 phone room #11, Unit AM-12 room #9, Unit AM-12 supply room, second floor hallway walls, rooms 2-7, 2-33 and 2-35 had excessive areas of peeling paint
-Room #7 had a hole in the wall behind the door
-The shower room on Unit AM-9 had rust staining on the walls of the left stall originating from the safety grab bar
-The shower room on Unit AM-10 had broken floor tiles
-The interior walls of the elevator passenger car were found to be broken, peeling and in overall poor condition exposing the wooden substructure of the wall

3. A tour of the Eleanor Slater Hospital-Roosevelt Benton Center building was conducted on 9/16/2021 with the Administrator of Safety and Security, the Associate Director of BHDDH, and the Chief Property Manager-Special Projects of DCAMM. The following environmental issue was revealed:
-The bathroom ceilings had excessive areas of peeling paint

Surveyor review of the open work orders for the Regan building, AM building, Benton Center and Zambarano Beasley building revealed there many outstanding issues, some of them dating back as far as 2015.

Staff interviews were conducted with the Administrator of Safety and Security, the Associate Director, and the Chief Property Manager-Special Projects DCAMM during the tours of the buildings on 9/13/2021, 9/14/2021, 9/15/2021 and 9/16/2021. They all acknowledged that the open work orders, included those dating back to 2015 and current outstanding issues need to be corrected.

Based on record review and employee (EMP) interview, the hospital failed to implement an infection prevention and control program including surveillance for 2 of 4 hospital buildings observed during survey. Additionally, the hospital failed to implement infection control measures to provide a sanitary environment and prevent the transmission of communicable diseases and infections relative to wound care for 1 of 3 sample patient with wounds, Patient ID #16 and 1 of 4 staff observed donning personal protective equipment (PPE), EMP-3.

Findings are as follows:

A. Review of the hospital's policy entitled "Visitation Protocol -Regan, Adolf Meyer, and Zambarano" last updated 6/2021, states in part:

"...5. Visitors enter at the designated entrance for each building...and register with Security...

7. Visitors will participate in a screening process for potential illness including temperature upon entering the building..."

1. The surveyor presented to the Adolf Myer building of the hospital on 9/14/2021 at approximately 7:20 AM and on 9/16/2021 at approximately 8:00 AM, signed in with Security, was provided with a visitor badge and was escorted to one of the units of the hospital, without having a temperature check or being screened for signs and symptoms of COVID-19.

During a surveyor interview with both the Nurse Manager, EMP-13, and the Supervising Nurse (SRN), EMP-14, on 9/16/2021 at approximately 12:00 PM, they both indicated that anyone visiting the building should be asked if they have been previously screened at one of the other buildings on the hospital's campus that day and if not, they should be screened by the SRN.


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2. The surveyor presented to the Zambarano building of the hospital on 9/13, 9/14, 9/15, 9/16 and 9/17/2021, the surveyor was not screened for signs and symptoms of COVID-19, including a temperature check.

During an interview with the Risk Manager EMP-29, on 9/17/2021 at approximately 12:30 PM, she/he stated she/he expects that all who enter the buildings are screened for COVID-19 and was unable to explain why the hospital's protocol for screening visitors for COVID-19 was not followed.

B. The hospitals "Hand Hygiene Program" policy, last revised in January 2020, states in part,

" 1. Indications for Handwashing and Hand Antisepsis .... h. Decontaminate hands if moving from a contaminated body site to a clean-body site during patient care ...

4. Other Aspects of Hand Hygiene... c. Change gloves during patient care if moving from a contaminated body site to a clean body site ..."

The hospitals "Transmission Based Precautions" policy, last revised in 1/2020, states in part, that for patients on
"Enhanced barrier precautions Level 1," staff are required to wear a gown and gloves "during high-contact patient care activities that have been found to increase the risk of MDRO [multi-drug resistant organism] transmission." The policy further states that such patient care activities include, but are not limited to, bathing/showering, transferring, and changing linens.

1. On 9/15/2021 at 9:40 AM, surveyor observed EMP-2 perform a dressing change. EMP-2 removed the soiled dressing and packing from Patient ID # 16's right buttocks wound and cleansed his/her sacral wound. EMP-2 failed to remove his/her gloves and perform hand hygiene before performing the wound packing and dressing treatment to the patient's right buttocks and applying a clean dressing to the patient's sacral area. Additionally, after removing the contaminated dressing, EMP-2, removed scissors and gauze from the clean area (across the room) with his/her dirty gloves and placed the scissors back in that area without cleaning them.

During surveyor interview with EMP-2 on 9/15/2021 at 9:55 AM, he/she acknowledged that he/he did not change his/her gloves and perform hand hygiene after cleaning the wounds and in between each dressing change. Additionally, he/she acknowledged that he/she retrieved clean supplies with contaminated gloves on and placed contaminated scissors in with the clean supplies.

2. Review of the medical record from Patient ID #15 revealed she/he is on enhanced barrier precautions Level 1 for having a colonized (in the body) multidrug resistant organism.

On 9/16/2021 at 10:50 AM, the surveyor observed EMP-3, a certified nursing assistant (CNA), assisting with transferring the patient from the bed to chair and collecting bed linens without wearing a gown. Additionally, when he/she was asked by the RN to don a gown, he/she inappropriately placed the gown on with the ties in the front and not tied, which resulted in his/her uniform being exposed.

During surveyor interview with EMP-20, the RN who asked EMP-3 to don the gown during the observation, she acknowledged that EMP-3 was incorrectly wearing her gown.