Other·March 6, 2023

The following reflects the findings of the California Department of Public Health during the Re-Certification survey from 2/6/2023 to 2/14/2023: State Citation B was written Event ID: 2X2Y11 F880 §483.80 Infection Control The facility must establish and maintain an infection prevention and controlprogram designed to provide a safe, sanitary, and comfortable environment and tohelp prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) thatmust include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, andcontrolling infections and communicable diseases for all residents, staff, volunteers,visitors, and other individuals providing services under a contractual arrangementbased upon the facility assessment conducted according to §483.70(e) and followingaccepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, whichmust include, but are not limited to: (i)A system of surveillance designed to identify possible communicable diseasesor infections before they can spread to other persons in the facility; (ii)When and to whom possible incidents of communicable disease or infectionsshould be reported; (iii)Standard and transmission-based precautions to be followed to preventspread of infections; (iv)When and how isolation should be used for a resident; including but notlimited to: (A) The type and duration of the isolation, depending upon the infectiousagent or organism involved, and (B)A requirement that the isolation should be the least restrictive possiblefor the resident under the circumstances. (v)The circumstances under which the facility must prohibit employees with acommunicable disease or infected skin lesions from direct contact withresidents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in directresident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCPand the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so asto prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCPand update their program, as necessary. The facility failed to maintain an infection prevention and control program to prevent the spread of infections as evidenced by: 1. The facility failed to use the proper disinfectant to disinfect shared (used for multiple residents) glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to manufacturer's instructions and accepted professional standards for 41 of 41 residents when: 1a. Licensed Vocational Nurse A (LVN A) failed to properly disinfect a shared glucometer during observation for two of 41 residents (Residents 9 and 25) according to manufacturer's instructions; 1b. Licensed nurses in three out of three nursing stations: LVN B, LVN C, LVN E, LVN F, LVN G and Registered Nurse D (RN D), did not know the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions; and, 1c. The Infection Preventionist/Director of Staff Development (IP/DSD) did not know the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions. Furthermore, concurrent interview and record review with the IP/DSD reflected there had been no staff in-services provided regarding proper disinfection of shared glucometers since 2021. The facility identified 41 residents that had active physician orders for Finger Stick Blood Glucose (FSBG, a procedure where the finger is pricked with a poking device to obtain a blood sample to measure blood glucose level) checks. One out of 41 residents (Resident 90) also had a diagnosis of Chronic Viral Hepatitis B (a serious liver infection caused by the hepatitis B virus that is most commonly spread by exposure to infected body fluids) at the time of admission on 7/19/21. As of 2/6/23, Resident 90 did not have a designated glucometer and had been given FSBG checks daily with a shared glucometer. The facility's noncompliance with infection control procedures had the potential to cause the development and the widespread transmission of bloodborne diseases (such as HIV [human immunodeficiency virus, is a virus that attacks the body's immune system], Hepatitis B, and Hepatitis C) to 41 of 41 residents. It was unknown when the noncompliance began according to an interview with the DON. Due to the widespread lack of knowledge of proper disinfection procedures demonstrated by eight (8) nursing staff, including IP/DSD, the facility needed to take immediate action to correct the non-compliance. On 2/6/23 at 5:45 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and declared, in the presence of the facility's Administrator and Administrator In Training (AIT), due to the facility's failure to ensure that LVN A properly disinfected a shared glucometer for two of 41 residents (Residents 9 and 25) according to manufacturer's instructions; failure to ensure LVN B, LVN C, LVN E, LVN F, LVN G and RN D knew the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions; failure to ensure the IP/DSD knew the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions; and not having staff in-services provided regarding proper disinfection of shared glucometers since 2021. On 2/7/23, at 3:30 p.m., the Administrator submitted an acceptable IJ Removal Plan ([IJRP], a plan with interventions to immediately correct the deficient practices). The acceptable IJRP included the following corrective actions: 1. Identify residents whose blood sugars (BS) need to be monitored. All residents (41 residents) on FSBG checks will be monitored for the following symptoms (ascites [condition in which fluid collects in spaces within your abdomen], tremors, confusion, vomiting of blood, blood in the stool and fatigue) per the Medical Director for 14 days. Resident[s] directly affected will have lab works done on 2/7/2023 for hepatitis B and C. 2. IP/DSD/Designee in-service and educated facility and/or registry licensed nursing staff (nurses employed through a contracted agency) on the glucometer manufacturer's guidelines for proper cleaning and disinfecting and return demonstration done to ensure it is done correctly. a. Glucometer to be cleaned and disinfected immediately after resident use (Sani-Cloth or equivalent) with 2 minutes wet time. b. Check if glucometer is in proper working condition prior to use. c. Daily QA (quality assurance) maintenance of each glucometer and to ensure glucometer is in proper working condition and if Licensed Nurses are cleaning/disinfecting it according to manufacturer's guidelines and proper use of recommended wipes. 3. IP/DSD/Designee will randomly perform spot check on all shifts daily × 2 weeks then monthly, and findings will be reported to QAPI (Quality Assurance and Performance Improvement) Committee. 4. IP/DSD/Designee in-service and education will be completed with the licensed nursing staff prior to the start of their shift and by 02/07/2023. 5. Corrective Action Plan reviewed at QAPI Committee Meeting on 02/07/2023. 6. A separate glucometer machine was provided for the resident identified with hepatitis, cleaned after each use and routine QA started. (forms/Sig [signature] attached) 7. Skills competency glucometer cleaning/disinfectant in serviced to Licensed nurse by IP/DSD/Designee. 8. P and P [Policy and Procedure] on bloodborne pathogens updated according to updated systemic changes and discussed and approved by QAPI Committee. On 2/8/23, at 9:48 a.m., the Department of Public Health removed the IJ while onsite after the surveyors verified the facility implemented the facility's IJRP by observations, interviews, and record reviews. The DON, Administrator, AIT and DSD/IP were informed. 2. The Director of Nursing (DON) and IP/DSD did not know the disinfectant wipe manufacturer's instructions for wet time (the amount of time disinfectants need to remain wet on surfaces to properly disinfect); and LVN B and RN H did not allow enough wet time, according to the manufacturer's instructions, during the disinfection of a shared glucometer for three of 41 residents (Residents 25, 39, and 97). 3. A nurse (LVN I) failed to perform hand hygiene between tasks during medication administration for one of 6 residents (Resident 72). 4. Four nursing staff (Certified Nursing Assistants R, S, U and LVN X) failed to wear proper PPE (Personal Protective Equipment - protective equipment used when caring for patients to prevent the spread of diseases) when working in facility areas that required them. 5. A nurse (LVN X) failed to take her temperature with a thermometer and screen for COVID-19 upon entering the facility to start work. 6. Nursing and maintenance staff failed to maintain oxygen concentrators in good working condition for two of two residents (Residents 15 and 24) with oxygen concentrators when the filters of their oxygen concentrators had a layer of grayish matter buildup on them. These failures placed residents at increased risk of healthcare-associated infections. Findings: 1a. During a medication administration observation on 2/6/23, at 8:36 a.m., with Licensed Vocational Nurse A (LVN A), a registry nurse, at Station 2, LVN A completed a blood check on Resident 25 with a glucometer. She placed the glucometer on the top of the medication cart without cleaning or disinfecting it. At 8:40 a.m., LVN A moved down the hall to Resident 9's room and prepared medications for Resident 9. She brought the prepared medications along with the same glucometer used for Resident 25, without wiping it down first, to Resident 9's bedside. At 8:49 a.m., LVN A administered the medications. After medications were given to Resident 9, LVN A was asked to exit Resident 9's room before completion of the BS check. During a concurrent observation and interview on 2/6/23, at 8:53 a.m., with LVN A, when asked how the shared glucometer was disinfected between Resident 25 and Resident 9, LVN A stated she used alcohol wipes. LVN A stated she did not know the facility's procedure for glucometer disinfection. LVN A reached for the Lysol wipes (a common household disinfecting wipe typically found at grocery stores) in the medication cart and wiped the glucometer with a Lysol wipe. LVN A stated she needed to ask a supervisor about the glucometer disinfection procedure because she did not know it. After a few minutes, LVN A returned to the medication cart and stated, "They [supervisor] said Lysol wipe is ok." At 9:08 a.m., LVN A completed the BS check for Resident 9 with the shared glucometer. 1b. During an interview on 2/6/23, at 9:45 a.m., with LVN B, at Station 3, when asked about the glucometer disinfection method, LVN B stated she used alcohol wipes to clean and disinfect it, and the wet time should be three minutes. She stated the glucometers were shared among residents. During an interview on 2/6/23, at 10:35 a.m., with LVN C (a registry nurse), at Station 1, LVN C was asked about the glucometer disinfection method, LVN C stated she used Lysol wipes to clean and disinfect it. During an interview on 2/6/23, at 4:05 p.m., with LVN E, at Station 2, LVN E stated the glucometer was used for all residents at the nursing station and alcohol wipes were used to clean the glucometer between residents. LVN E stated she did not know the wet time. During an interview on 2/6/23, at 5:01 p.m., with RN D, at Station 1, when asked about the facility's glucometer disinfection method, RN D stated, he used Lysol wipes with a two-minute wet time. RN D stated he did not remember when an in-service about glucometer disinfection was provided, but he remembered there was one. During a concurrent observation and interview on 2/6/23, at 5:05 p.m., with LVN E, at Station 1, LVN E used alcohol wipes to clean a glucometer after a BS check was completed. LVN E then placed the glucometer inside the medication cart. When asked how to disinfect shared glucometers, LVN E stated she used alcohol, Lysol, or whatever was available in the cart. When asked about the wet time, LVN E stated, "It dries by itself." During an interview on 2/6/23, at 5:11 p.m., with LVN F, at Station 2, when asked about the facility's glucometer disinfection method, LVN F stated she wiped the glucometer with alcohol wipes and dried it with the tissue. LVN F stated it could take 5 to 10 minutes to dry. LVN F stated an in-service on glucometer cleaning was provided in 2022. During an interview on 2/6/23, at 5:14 p.m. with LVN G (a registry nurse), at Station 3, LVN G stated it was her first day of work at the facility. LVN G stated she had not completed a BS test yet, but had to do one later. When asked how to clean and disinfect the glucometer, LVN G stated she would use alcohol swabs to clean the glucometer. LVN G showed a small basket that contained a glucometer and alcohol swabs. LVN G stated no in-service was given regarding glucometer disinfection upon orientation. 1c. During a concurrent interview and record review on 2/6/23, at 4:09 p.m., with the IP/DSD, the IP/DSD reviewed the facility's binder that contained documentation of nursing staff in-services/training completed between January 2021 to February 2023. The IP/DSD confirmed there were no in-services/training or competencies completed by licensed nurses regarding the facility's procedure for cleaning and disinfecting shared glucometers. During an interview on 2/6/23, at 5:22 p.m., with the IP/DSD, the IP/DSD stated, there were no in-services since 2021. When asked how staff cleaned and disinfected glucometers, the IP/DSD stated, with the Lysol "yellow [package] or purple [top] disinfectant wipes." The IP/DSD stated, "We tell the staff to use Lysol disinfectant." The IP/DSD stated alcohol is not an antiviral (A drug used to treat infections caused by viruses) or disinfectant and should not be used. The IP/DSD was asked by a surveyor if Lysol kills hepatitis or HIV, the IP/DSD reviewed the Lysol package instructions and stated, "No, it doesn't." The IP/DSD stated she did not know what the glucometer manufacturer recommended to use for disinfection of the glucometer. The IP/DSD stated she was not aware that the nursing staff used alcohol to disinfect the glucometers. She said glucometer disinfection instructions were not part of the orientation for registry nursing staff. During a review the product labeling for the Lysol disinfectant wipes provided by the facility, it indicated, "Kills Salmonella [a bacteria that can cause an infection in the intestinal tract through contaminated water or food], Influenza A Virus (H1N1) [a virus that causes an infection of the nose, throat and lungs], Herpes Simplex Virus Type 1 [a virus that causes herpes infection], Staphylococcus aureus [a bacteria found on human skin], Escherichia coli [E.Coli, a bacteria that is commonly found in the lower intestine] and Respiratory Syncytial Virus [RSV, a common respiratory virus that causes cold-like symptoms] on hard, non-porous surfaces in 4 minutes ...To Disinfect: Allow [surface] to remain wet for 4 minutes. Allow surface to air dry ..." The Lysol disinfectant wipes did not contain a disinfectant that would protect against bloodborne infectious diseases such as Hepatitis B, Hepatitis C, or HIV. On 2/6/23, the facility provided a list of residents with physician's orders for FSBG in the facility. The list identified 41 residents. During a review of Resident 90's "Admission Record," dated 7/19/21, it indicated, Resident