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Based on observation, record review and interview the facility staff failed to ensure the physical environment was maintained in a safe manner to ensure the well being of patients in 3 of 3 patient units observed (Unit 1, Unit 2, Unit 5); and failed to follow policy and procedure to mitigate the risk of a potential bed bug infestation in 1 of 3 patient units (Unit 2), in a total sample of 3 units observed.

Findings Include:

The facility staff failed to ensure the physical environment was maintained in a safe manner to ensure the well being of patients. See Tag A-701.

The facility staff failed to follow policy and procedure to mitigate the risk of a potential bed bug infestation. See Tag
A-701.

Based on observation, record review and interview the facility staff failed to ensure the physical environment was maintained in a safe manner to ensure the well being of patients in 3 of 3 patient units observed (Unit 1, Unit 2, Unit 5); and failed to follow policy and procedure to mitigate the risk of a potential bed bug infestation in 1 of 3 patient units (Unit 2), in a total sample of 3 units observed.

Findings Include:

Review of policy and procedure #16533606 titled, "Bed Bugs" effective 02/06/2024 revealed the following:
- Preventative: "Upon admittance, patients will be required to put on paper scrubs. Their belongings will then be placed in plastic bags. Clothing will be washed, and dried on the highest possible setting..."
- "The following procedures are to be implemented immediately upon the detection or concern of a bed bug infestation: These steps must be performed as posted and in a timely manner to avoid a major infestation. 1. Infection control and Plant Ops (operations) should be contacted immediately at the first signs of the presence of bed bugs...2. All patients occupying the same bedroom must return to their room and remove all clothing and be provided paper scrubs. All clothing...should be placed in a water soluble bag and placed directly into a washing machine. The water should be set at the highest temperature available...once washed, clothes go directly into the dryer and again, be at its highest setting...4. All furniture should remain in the room to be treated...Mattresses should be disinfected...Pillows should be thrown away. 5. Housekeeping services should be contacted so room can be cleaned...All furniture cracks and crevices should be vacuumed...All interiors of dressers and wardrobes should be vacuumed...Vacuum should be brought directly outside of hospital, the vacuum bag should be placed in a plastic bag and be properly disposed of directly into the trash dumpster. 6. Room should be locked and appropriate signage placed on door. 'Room out of service, Plant Ops/Housekeeping staff only to enter.' 7. Plant Ops/Housekeeping staff will use a steam machine...8. Contracted Pesticide Company to be notified to come in and chemically treat room and furniture. 9. Plant operations and Infection Control Preventionist will check the room on a daily basis and determine when the room is ready to re-occupy...10. Once room is clear to re-occupy the housekeeping department will conduct a terminal clean."

Review of policy and procedure #15104447 titled, "Environmental Cleaning" effective dated 08/31/2024 revealed the following:
- "Final accountability for all aspects of cleanliness rests with Administration."
- "The Director of Facilities Management (Plant Ops) and the Department Directors are responsible for...ensuring national guidance on cleanliness and associated environment service initiatives are interpreted and implemented in conjunction with Infection Control and Environmental Services."
- "Environmental services staff are responsible for carrying out cleaning of the general environment..."
- "All staff are responsible for ensuring high standards of cleanliness with regard to...environment of care...including, but not limited to...floors...should be visibly clean with no...dirt, debris, dust..."

On 09/10/2024 beginning at 11:20 AM, while touring the hospital with Director of Risk B, observed the following environmental concerns:
Unit 5:
- Unoccupied "clean" rooms #2054, 2061, and 2060 contained accumulated dust, debris, and/or dead insects on the floor near the baseboards by the window, shelving unit, bed frame, and in the corners of the room.
- In room #2061, the bathroom contained strands of hair in the sink and on the counter top.
- On unit #1, 2, and 5, the floors of the "clean" storage and linen closets contained an accumulation of dust, debris, supplies, packaging material and/or dead insects.
- On unit #5, observed a live insect crawling on the floor in the common hallway.

Per interview with Director B at the time of the observations on 9/10/2024 beginning at 11:20 AM, Director B confirmed the findings and stated the floors should be clean.

Per interview with Mental Health Technician (MHT) M on 09/10/2024 beginning at 11:40 AM, MHT M stated that room #2054, #2061, and #2060 were cleaned and "ready for new admit."

Per interview with Director of Plant Operations H on 09/10/2024 beginning at 4:00 PM, Director H stated that the expectation is that every room is inspected daily by housekeeping staff even if it is clean and unoccupied. Director H stated that storage and linen closets should be cleaned daily.

Review of Pt #1's medical record revealed Pt #1 was admitted to the behavioral health hospital Unit 2 on 08/01/2024 at 8:56 PM with Suicidal Ideations and a history of depression; Pt #1 was discharged on 08/07/2024 at 2:17 PM.

Review of Registered Nurse (RN) I's Daily Nursing Assessment Progress Note dated 08/02/2024 at 4:40 PM, revealed, "(Pt #1) denied any physical discomforts...on his clothing what appeared to be a bed bug was seen, (Pt #1) was asked to remove all his clothing and followed the protocol...(Pt #1's) linen were removed, (Pt #1's) roommates clothes [sic]."

Review of Pt #3's medical record revealed Pt #3 was admitted to the behavioral health hospital Unit 2 on 07/31/2024 at 6:00 PM for Suicidal Ideations. On 08/03/2024 (no time) Pt #3 was discharged against medical advice after a "Request For Discharge" (no reason for request was documented).

Review of patient list titled "Patient Visits Active in 08/02/2024...to 08/11/2024..." provided by staff revealed, Pt #3 was Pt #1's roommate on 08/02/2024 from admission on 07/31/2024 at 8:31 AM to discharge on 08/03/2024 at 8:31 PM.

Per interview with Director B on 09/11/2024 beginning at 12:53 PM, Director B was unable to confirm the exact room location of the patients each day and stated that the medical records documentation was "unclear" and does not show when patients are moved to different rooms.

Per interview with MHT D on 09/11/2024 beginning at 1:23 PM, MHT D stated that she/he found the bed bug on Pt #1's shoulder while Pt #1 was in the hallway of Unit 2 on 08/02/2024. MHT D stated that she/he escorted Pt #1 to the Exam room on Unit 2 and Pt #1 removed clothing in the Exam room (per policy this should be done in the patients room) and donned green paper scrubs; MHT D stated that she/he placed Pt #1's cloths in a blue bag (not water soluble) and left the bag in the Exam room. MHT D stated that she/he did not ensure Pt #1 showered as per policy. MHT D stated that Pt #1 "probably" had a roommate and "probably was still in the room." MHT D stated that a sign was not placed on Pt #1's door as per policy (Room out of service, Plant Ops/Housekeeping staff only to enter); MHT D stated that the room was not immediately blocked off as per policy. Per MHT D, the room was not blocked off between Friday 08/02/2024 and Monday 08/05/2024. Per MHT D, the bedbug was shown to and confirmed with a nurse and then placed in a red specimen bag and thrown away. MHT D stated that she/he was not trained on how to handle bed bugs and was trying to "Google" what to do. MHT D stated that she/he was not aware that the patient's clothing needed to go in a "water soluble" bag as per policy and MHT D was not aware of the process for washing clothes when addressing a potential bed bug infestation.

Per interview with the Assistant Director of Nursing (ADON) J on 09/11/2024 beginning at 12:08 PM, ADON J stated that Pt #1 was identified with a bed bug on Friday 08/02/2024. ADON J stated that she/he directed staff to place Pt #1 and roommate (Pt #3) in a different room but ADON J stated that she/he found out later this did not happen. ADON J stated, "My recollection is that one patient was left in that room," Per ADON J, she/he was told by staff on Monday 08/05/2024 that Pt #1 was moved out, but the roommate (Pt #3) was left in the room (until request for discharge on Saturday 08/03/2024). ADON J stated that she/he could not confirm if Patients (Pt #1 & Pt #3) showered. ADON J stated patients were not placed on contact precautions as per policy. ADON J stated that she/he does not remember if Infection Preventionist and Maintenance were contacted, but stated, "We usually do."

Per interview with Housekeeper N on 09/10/2024 beginning at 1:20 PM, Housekeeper N stated that rooms with potential bed bug infestation are "blocked...I don't go in them." Housekeeper N stated that pest control sprays first and then when given the ok, housekeeping staff will complete a terminal cleaning (this is inconsistent with the Bed Bug policy which revealed that Housekeeping staff should be contacted to clean the room as per policy).

Per interview with Director of Plant Operations H on 09/10/2024 beginning at 4:00 PM, Director H stated he/she was not made aware of the bed bug incident until 08/04/2024 Sunday night (2 days after bed bug found) via a phone call from Housekeeping staff. Director H stated that the Pest Control company came to chemically treat the unit on Monday 08/05/2024 (3 days after incident). Director H stated that this was the only time he/she was made aware of a bed bug sighting. Director H stated that staff should notify Maintenance immediately after finding a bed bug. Director H stated that pest control treats the room first and then Housekeeping staff go into a room to terminally clean; per Director H, Housekeeping staff are not allowed in the room until cleared by the Pest Control company (this is inconsistent with the Bed bug policy which revealed the Housekeeping staff should be contacted to clean the room). Director H stated that he/she did not know if the Infection Preventionist was involved in this incident; Director H stated that he/she gave the ok to release the room and the Infection Preventionist was not involved in that decision as per the Bed Bug policy requires.

Per interview with Infection Preventionist (IP) G on 09/10/2024 beginning at 3:33 PM, IP G was hired as a Nurse Educator and officially transitioned to the Infection Preventionist approximately 2 weeks ago. IP G stated that he/she was not aware of the incident involving bed bugs and was not aware of any increased monitoring or education occurring as a result of the bed bug incident. IP G stated that if a patient is found or suspected of having bed bugs, the room should be cleaned immediately, patients (including roommate) items put in a special bag to wash clothes, patients showered and given scrubs immediately and terminal cleaning to the Exam room. When asked who determines if the room is ready for a patient admission after the pest control is completed, IP G responded, "I would assume, if the pest company says it's ready, it's ready." Per Bed Bug policy Plant Operations and Infection Preventionist must do daily checks and determine if a room is ready to re-occupy.

Review of the Pest Control "Proof of Service" form revealed Bed Bug Sensitive Treatment was provided at the facility on 08/05/2024 at 4:04 PM (3 days after initial bed bug sighting).

Per interview with Director of Risk B on 09/11/2024 beginning at 12:53 PM; Director B confirmed that Infection Preventionist G was the IP for the last 5 months. Director B stated that Director B was made aware of the bed bug sighting on 08/02/2024 and administration discussed a plan to address Pt #1 and roommate. When asked about the plan implemented by administration in response to the bed bug incident, Director B was unable to recall the details and specifics. Director B stated that staff should have notified Infection Preventionist and Maintenance immediately. Director B was unable to show that Pt #1's roommate (Pt #3) was moved out of room. Director B stated that the Bed Bug policy was revised (09/10/2024) in response to this incident, however staff have not been educated on the policy revisions.

Per staff interviews there was no evidence that facility staff addressed the bed bug concern as per policy and procedure to mitigate the risk of a bed bug infestation within the facility.