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Based on record reviews and interviews, the hospital failed to ensure care in a safe setting. This deficient practice was evidenced by failing to ensure all staff had current CPR training as per hospital policy for 6 (S3MHT, S4LMSW, S5LPN, S7PA, S8MHT, S9HK) of 8 (S2DON, S3MHT, S4LMSW, S5LPN, S6PLPC, S7PA, S8MHT, S9HK) personnel records reviewed.

Findings:

Review of the hospital's policy titled "HR-003: Personnel Files", revised 08/2020, revealed in part, The personnel file should include, but not necessarily be limited to, the following:
Licensure/Certifications: -Copy of Professional Licensure; -Verification of Professional Licensure; -Education Verification; -Current CPR Certification; -Current CPI Certification.

Review of S3MHT, S4LMSW, S5LPN, S7PA, S8MHT, S9HK's personnel records failed to reveal current CPR certification.

In multiple interviews on 10/29/2024 at 12:52 p.m. - 2:01 p.m. S1CEO verified there was no documentation of current CPR certificates in the above stated personnel records. S1CEO verified all employees are required to have CPR training.

Based on observation, record review, and interview, the hospital failed to have an effective infection prevention and control program as evidenced by failing to have a clean and sanitary environment.

Findings:

Review of the hospital's policy titled "IC-300: Cleaning, Disinfection and Sterilization", revised 12/2020, revealed in part, Routine Cleaning: Area: Work Surfaces Procedure: To ensure worksites are maintained in a clean and sanitary condition and to implement an appropriate method of decontamination based upon the location, type of surface to be cleaned, type of contaminant present, and tasks or procedures being performed in the area.

Observation on 10/28/2024 at 1:21 p.m. - 1:40 p.m. of the outpatient facility revealed there were 18 out of 62 chairs throughout the 5 group rooms that the leather covering was peeling off the seat and/or back of the chair and could not be disinfected.

In an interview during the observation S1CEO verified the above stated findings.

Based on record reviews and interviews, the infection control preventionist failed to provide competency-based training and education of hospital personnel and staff on the practical applications of infection prevention and control guidelines, policies, and procedures. This deficient practice was evidenced by failing to have documentation of skill competencies that included infection control practices for 7 (S3MHT, S4LMSW, S5LPN, S6PLPC, S7PA, S8MHT, S9HK) of 7 (S3MHT, S4LMSW, S5LPN, S6PLPC, S7PA, S8MHT, S9HK) personnel records reviewed for staff that were responsible for cleaning of the outpatient facility.

Findings:

Review of S3MHT, S4LMSW, S5LPN, S6PLPC, S7PA, and S8MHT's personnel records failed to reveal documentation of skill competency that included infection control practices. Review of S9HK's personnel record failed to reveal documentation of skill competency for the position of housekeeper.

In an interview on 10/29/2024 at 9:36 a.m. S1CEO verified all staff were responsible to clean the outpatient facility when there was no housekeeper.

In an interview on 10/29/2024 at 12:52 p.m. S1CEO stated every position has a skill competency required.

In an interview on 10/29/2024 at 1:47 p.m. S1CEO verified the skill competencies for the MHTs/drivers, therapists, and nurses of the outpatient facility did not include infection control practices.

In an interview on 10/29/2024 at 2:01 p.m. S1CEO verified S9HK's personnel record did not include documentation of skill competency for the position of housekeeper.

Based on record reviews and interviews, the hospital failed to have a qualified director of psychiatric nursing services. This deficient practice was evidenced by the director of psychiatric nursing services failed to have a master's degree in psychiatric or mental health nursing or be qualified by education and experience in the care of the mentally ill.

Findings:

Review of S2DON's personnel record revealed a hire date of 01/23/2023. Review of S2DON's application and resume failed to reveal prior experience of psychiatric nursing or care of the mentally ill. Further review of S2DON's personnel record revealed an Associate of Science in Nursing Degree.

In an interview on 10/29/2024 at 2:26 p.m. S2DON verified he has an associate's degree in nursing. S2DON verified he does not have a master's degree. S2DON stated he was an employee at 'hospital A' in the nineties. He then stated from 1995-2001. S2DON stated while he was employed there he did some shifts in the adult psychiatric unit. S2DON stated he was a pool nurse and was pulled to the psychiatric unit during that time. S2DON stated while he was employed at 'hospital B' in 2010-2012 he was the House Supervisor. S2DON stated he was always going to the psychiatric unit as the house supervisor. S2DON verified he had not been employed by a psychiatric hospital or psychiatric unit prior to being hired as the DON at this psychiatric hospital. S2DON verified this hospital had not implemented a contract with a nurse with a Master's degree in Psychiatric Nursing.